Counseling Personal Data Inventory

This form is a little lengthy, and some questions may not seem relevant, however, it has been built up out of our experiences as counselors. Bethel Baptist and its counselors are not licensed counselors, but continue to do ongoing training to learn how to best apply God's word to your situation. We hold confidently to the premise that God's Word can and will speak into your situation if you will let it. If it is decided that other sources outside of Bethel Baptist would best serve you, we will discuss that with you.

Personal Identification

Name

Birthdate

Address

This address will receive a confirmation email

Phone

Age

Gender

Referred By

Marital Status

Education (last year completed):

Employer

Position

Years @ current job?

Currently Attending School?

Weekly work/school hours:

Marriage & Family

Spouse

Birthdate

Age

Occupation

How Long Employed

Phone

Date of Marriage

Length of Dating

Brief Statement of how you met

Either of you previously married?

To Whom?

Ever been separated?

Filed for divorce

Information about Children: Name: Age: Gender: Living: Year Ed.: Step-Child:

Describe relationship to your father:

Describe relationship to your mother:

Number of siblings

Your order in the siblings

Do you (or have) you lived with anyone other than parents:

Parents still married?

Mother still living? If not how did she pass?

Father still living? If not how did he pass?

Parents live locally?

Parent’s religious convictions, were/are they believers:

Health

Describe your overall health:

Describe any chronic conditions, important illnesses, injuries, or handicaps:

Date of last significant medical exam: Label

Report of that visit

Do you have a family doctor or physician you see regularly?

Current medication(s) and dosage:

Have you ever-used drugs for anything other than medical purposes:

If yes, please explain:

Have you ever been arrested:

If yes, please explain:

Do you drink alcoholic beverages:

If so, how frequently and how much:

Do you drink caffeinated drinks?

What and how much

Use Tobacco:

What form & how frequent?

Describe your normal sleeping schedule:

Have you ever had interpersonal problems on the job:

Have you ever had a severe emotional upset:

Have you ever seen a psychiatrist or counselor:

Are you willing to sign a release of information form so that your counselor may write for social, psychiatric, or other medical records (if needed):

Spiritual

Denominational preference:

Name of church you are attending & are you a member there?

Pastor’s Name:

Pastor’s Phone Number:

Church attendance:

Do you believe in God:

Do you pray:

Are you a Christian

Have you ever been baptized (when & Where):

Are you involved in Christian ministry of any kind. (If so, please explain):

How often do you read the Bible:

Have you ever been discipled? If yes, please describe:

Explain any recent changes in your religious life:

What are the three biggest positive influences on your spiritual life:

What are the three biggest negative influences on your spiritual life:

Have you shared the problems for which you are seeking counseling with your pastor and/or other mature members of your church? If yes, please write down their names. If no, please describe any concerns you have about doing so:

Other

Is your spouse willing to come for counseling:

Is (s)he in favor of your coming? If no, please explain:

If other please Explain:

Why have you sought counseling? What difficulties are you facing?

What have you done about the difficulties?

What are your expectations from counseling?

Is there any other information that we should know?

Women Only

Have you had any menstrual difficulties:

If you experience tension, tendency to cry, other symptoms prior to your cycle, please explain:

By typing "Yes" I hereby understand that I will be receiving biblical counseling from the Bible by a member of Bethel Baptist Church to the best of his or her ability.

Counseling Personal Data Inventory

Description

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