Counseling Personal Data Inventory

Grace Biblical Counseling, LLC Personal Data Inventory
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
BASIC INFORMATION
Name:
Home phone:
Format: (000) 000-0000.
Cell phone:
Format: (000) 000-0000.
Email:
Address:
Referred by:
Times available:
What books, movies, TV have you viewed in the last 6 months?
FAMILY INFORMATION
Marital Status:
List your children and grandchildren (names, ages, living at home, married):
List your brothers and sisters with their ages (indicate deceased siblings, if any):
EDUCATION & EMPLOYMENT
Highest education level:
Describe major/specialty, if applicable:
Place of employment:
Position:
RELIGIOUS BACKGROUND
Are you a believe in Jesus Christ as your Lord and Savior?
If yes, describe the circumstances of your conversion:
If yes, what are you doing on a regular basis to grow in your relationship with the Lord?
List your current church membership and year begun:
Describe ministries in which you are involved:
Are you in a small group sponsored by your church? If so, who is the leader?
List any current discipleship/mentoring/accountability relationships (type and with whom):
In what areas would you like to grow in your walk with the Lord?
HEALTH INFORMATION

(this will be kept confidential)
How would you rate your physical health?
Have you recently had any weight changes (indicate pounds)?
List all past or present illnesses, handicaps, injuries, and hospitalizations:
Date of last medical exam:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Exams within the last year:
List any medications and/or supplements that you are presently taking and long you have been taking them:
Have you ever used drugs for other than for medical purposes? List which ones and when:
Have you ever had a severe emotional upset? Explain:
Have you ever attempted suicide?
Have you ever had any therapy or counseling? List therapist, counselor, dates, and results:
Physical symptoms you are currently experiencing today:

Other
What emotional symptoms are you currently experiencing?

Other
Is there anything else that you would like us to know about you?
COUNSELING EXPECTATIONS
Is there a crisis in your life right now? If so, describe conditions and effects:
What is the problem that brings you to counseling?
What have you done about it so far?
What expectations do you have regarding this counseling?
What reservations or concerns do you have about seeking counseling?
Should be Empty:

BASIC INFORMATION

FAMILY INFORMATION

EDUCATION & EMPLOYMENT

RELIGIOUS BACKGROUND

HEALTH INFORMATION

COUNSELING EXPECTATIONS