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 Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation
Business Phone Number
Please enter a valid phone number.
Birthdate
-
Month
-
Day
Year
Date
Gender
Male
Female
Age
Marital Status
Please Select
Single
Married
Divorced (Single)
Divorced (Remarried)
Separated
Education
Please Select
Elementary
Middle School
High School
Associate's
Bachelor's
Master's (or higher)
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 Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation
Phone Number
Please enter a valid phone number.
Religion
Does your spouse know you are coming for counseling?
Yes
No
Type option 3
Type option 4
Have you ever been separated?
Yes (currently)
Yes (in the past)
No
Your ages when married
Type your age, then your spouse's
Anniversary Date
-
Month
-
Day
Year
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?
Yes
No
Have you ever had any psychotherapy or counseling before?
Yes
No
List counselor(s) or therapist(s) and dates
What was the outcome?
Check off any of the following words which best describe you now.
Active
Hardworking
Excitable
Shy
Leader
Lonely
Ambitious
Impatient
Imaginative
Fearful
Quiet
Self-Conscious
Self-Confident
Impulsive
Calm
Introvert
Inflexible
Bitter
Persistent
Moody
Serious
Extrovert
Submissive
Angry
Anxious
Often Sad
Easy Going
Likable
Sensitive
At any time have you:
Felt people were watching you?
Had difficulty recognizing faces?
Been unable to judge distance?
Had visual hallucinations?
List fears you have
Have you ever been arrested?
Yes
No
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
AM/PM Option
When do you get up?
Hour Minutes
AM
PM
AM/PM Option
Rate your health
Very good
Good
Average
Declining
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
-
Month
-
Day
Year
Date
What was the report?
Name and location of your physician
Are you presently taking medication?
Yes
No
If so, what?
Have you used drugs for other than medical purposes?
Yes
No
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.)
Yes
No
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?
Yes
No
Who is your pastor?
List only one for primary contact
What is the number of church services you attend per month?
Church attended in childhood
Do you believe in God?
Yes
No
Do you pray to God?
Yes
No
Have you been baptized?
Yes
No
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?
Yes
No
On what is your greatest hope in life (and death) based upon?
Are you saved?
Yes
No
Religious background of spouse
How much do you read the Bible?
Does your family regularly read the Bible and pray together?
Yes
No
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?
Submit
Should be Empty: