Personal Data Inventory

Permission to leave a message?    Please Select Yes No    

Permission to leave a message?    Please Select No Yes Type Option 3    

Age

Gender    Please Select Male Female    

Have you used drugs for other than medical purposes?    Please Select Yes No    

Do you drink alcoholic beverages?    Please Select Yes No    

Do you smoke?    Please Select Yes No    

Do you use any sleep aids or herbs?    Please Select Yes No    

Is he living?    Please Select Yes No    

Is she living?    Please Select Yes No    

Which parent were you closest with?    Please Select Father Mother Other    

Were you raised by anyone other than your biological parents?    Please Select Yes No    

Are you currently separated?    Please Select Yes No    

Has either of you ever filed for divorce?    Please Select Yes No    

Have you ever been married before?    Please Select Yes No    

Has your spouse ever been married before?    Please Select Yes No    

Do you have any child support responsibilities or income?    Please Select Yes No    

Are you a member of your church?    Please Select Yes No    

Does your family attend with you?    Please Select Yes No    

Is your pastor aware that you are seeking Biblical counseling?    Please Select Yes No    

Do you permit me to consult with your pastor?    Please Select Yes No    

Have you ever been or are you currently under church discipline?    Please Select Yes No    

Have you been baptized?    Please Select Yes No    

Do you believe the Bible is the Word of God and has authority in your life?    Please Select Yes No    

Are you forgiven by God?    Please Select Yes No    

Would you go to Heaven if you died?    Please Select Yes No Not Sure    

Do you pray to God?    Please Select Never Occasionally Often    

How often do you read the Bible?    Please Select Never Occasionally Often    

Do you read the Bible with your children?    Please Select Never Occasionally Often