PDI 1

Family Information
Name of Father:
Living?
Name of Mother:
Living?
Describe your parents' involvement in your life.
Parents are:

Never MarriedMarriedSeparatedDivorcedRemarried
Your age when parents separated:
Your age when parents divorced:
Were you raised by anyone other than your biological parents?
If so, please explain.
List your siblings, oldest to youngest including yourself.
Mark step-siblings with an asterisk (*).
Marriage Information
Name of Spouse
Age
Religion
Education
Employer & Occupation
Wedding Date and State
How old were you and your spouse when you married?
Your age first, spouse's second.
Length of Dating or Engagement Time?
Length of marriage?
Have you ever been separated?
If yes, state date and length of separation.
Have either of you ever filed for divorce?
If yes, state which partner filed and date of divorce.
Is your spouse willing to come to counseling if asked?
State briefly any information about any previous marriages that you and your spouse have had?
Please include the total number of marriages.
Relatives you are closest to:
Children
Children in birth order:
List name, Age, Gender, Living (Y/N), Occupation and Marital Status. Include an SC if it is your stepchild (no biological relation), NM if it is your biological child but you were not married to the other parent.
# of Miscarriages
# of Abortions
I may have other children I haven't met (Men only)

Briefly Answer the Following Questions:
What brings you to counseling?
Write a quick summary of your main concerns. Specify how long you have had these concerns.
What have you already done about these concerns? What have been the results?
What are your expectations and goals in coming here?
Is there any other information we should know?
From whom do you normally receive advice for problems?

FriendPastorRelative/FamilyNeighborCo-workerNo oneCounselor or Therapist
Who referred you to us?
Name and relationship to you.
Was your involvement in counseling placed on you as a requirement?
If so, please explain.
Should be Empty: