Personal Data Inventory (PDI-DM)

Personal Data Inventory (PDI-DM)

This form is to be completed by Biblical Counseling participants at least 2 business days prior to meeting for the first session with Daniel Maasen.
Identification Data
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation
Business Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Birthdate

MonthDayYear
Date
Gender
Age
Marital Status
Education
Select last completed
Degree
If applicable
Other Training
Include certifications, apprenticeships, etc.
Hobbies
Referred to us by
Relationship
To the person who referred you to us
If you were raised by anyone other than your own parents, briefly explain.
How many siblings do you have?
Describe where you are in birth order.
Include how many brothers/sisters are older and how many are younger in your answer.
Marriage Information

Skip this section if single.
Name of Spouse

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Religion
Does your spouse know you are coming for counseling?
Have you ever been separated?
Your ages when married
Type your age, then your spouse's
Anniversary Date

MonthDayYear
Date
How long did you know your spouse before marriage?
Length of steady dating with spouse
Length of Engagement
Give brief information about any previous marriages.
Give Name, Birthdate, Sex, Education, and Marital Status of Children, if any.
If none, say N/A. Place an asterisk by the name of any children from previous marriages. Note if any children are deceased.
History Information
Have you ever had a severe emotional upset?
Have you ever had any psychotherapy or counseling before?
List counselor(s) or therapist(s) and dates
What was the outcome?
Check off any of the following words which best describe you now.
At any time have you:
List fears you have
Have you ever been arrested?
Reason
If "yes"
Health Information
Approximately how many hours of sleep do you get each night?
When do you go to sleep at night?

Hour Minutes

AM/PM Option
When do you get up?

Hour Minutes

AM/PM Option
Rate your health

Other
Approximate Weight
Approximate Height
Recent weight changes
List pounds gained/lost and timeframe.
List all important present and past illnesses, injuries, or handicaps
Approximate date of last medical examination

MonthDayYear
Date
What was the report?
Name and location of your physician
Are you presently taking medication?
If so, what?
Have you used drugs for other than medical purposes?
List drugs used and timeframe
Are you willing to sign a release of information form so that your counselor may write for social, psychiatric, or medical reports? (Answering “yes” to this question is not required to be considered for counseling.)
Religious Background
Denominational preference
What church do you attend
Include the city in your answer if not GCC
May we contact your pastor for background information and (if necessary) to discuss necessary elements of your care?
Who is your pastor?
List one or multiple
What is the number of church services you attend per month?
Include weekly worship services and midweek activities
Church attended in childhood
Do you believe in God?
Do you pray to God?
Have you been baptized?
Have you come to the place in your spiritual life where you can say that you know for certain that if you were to die today you would go to heaven?
On what is your greatest hope in life (and death) based upon?
Are you saved?
Religious background of spouse
How much do you read the Bible?
Does your family regularly read the Bible and pray together?
Explain any recent changes in your religious life, if any
Five Basic Questions

Briefly answer the following questions.
What are the issues you are struggling with?
What have you done about it?
What do you want us to do?
What are your expectations in coming here?
What brings you here at this time?
Is there any other information we should know?
Should be Empty:

Personal Data Inventory (PDI-DM)

Identification Data

Marriage Information

History Information

Health Information

Religious Background

Five Basic Questions