INDIANA BIBLICAL COUNSELING CENTER
Confidential Client Inventory
Personal Information
Name:
Date:
-
Mês
-
Dia
Ano
Data
Address:
Endereço
Endereço (cont.)
Cidade
Estado
CEP/Código postal
Home Phone:
Format: (000) 000-0000.
Cell Phone:
Format: (000) 000-0000.
Email
exemplo@exemplo.com
Marital Status:
Single
Married
Divorced
Age:
Previous History of Marriage/Divorce:
Do you have any children? How many?
Ages:
What is your occupation?
Home Church:
Pastor:
Reason for Counseling:
How do you feel about receiving counseling?
Family History
How would you describe your relationship with your parents?
Father:
Mother:
Check the word(s) that describe the atmosphere in your home during your growing up years:
Loving
Abusive
Neglectful
Nurturing
Permissive
Rigid Tense
Legalistic
Controlling
Fun
Encouraging
Fearful
Caring
Crazy
Safe
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Spiritual Life
In your minds eye, if Jesus were looking at you, what facial expression would He have when He looks at you?
Why would He be looking at you that way?
Do you have regular quiet time and Bible study with God?
Yes
No
Do you find prayer difficult mentally?
Yes
No
Have you memorized or meditated on Scripture?
Yes
No
Are you plagued with doubts concerning your salvation?
Yes
No
Medical History
Do you have with any major health problems?
Have you been diagnosed with a psychological condition?
Are you currently taking any prescription medications related to your psychological or emotional stability?
Have you ever been hospitalized for emotional or psychological problems? If yes, please explain.
Have you ever experienced any type of trauma (i.e. physical, emotional, or sexual history of abuse, involvement in a severe accident, death of family member, ....? Please explain.
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Personal Conflicts
Check any of the following with which you are struggling.
Check any of the following with which you are struggling.
Depression
Inadequacy
Anxiety
Fear
Panic Attacks
Blasphemous Thoughts
Lustful Thoughts
Worry
Obsessive/Compulsive
Dissociation
Sadness (Grief)
Anger
Negative Thoughts
Insecurity
Stressed Out
Hopeless Despair
Shame/Guilt
Suicidal Thoughts
Bitterness
Pride
Sexual Impure Behavior
Rebellion
Perfectionism
Legalism/Performance
Boundaries
Unhealthy Relationships
Rejection
What are the greatest concerns in your life?
What are the greatest needs in your life?
Is there any other information we should be aware of that could be helpful in your counseling?
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