Cut Bank Community Bible Church
Thursday, December 14, 2017

Personal Data Inventory

 

 Please complete this form and click "Submit"

 

Identification Data:

Name            Address 

Occupation 

Business Phone              Home Phone 

Gender                              Birth Date                                             Age
                                  
 
Marital Status
 
Education (last year completed) :  (grade)
Other Training (list type & years)
Referred here by  
Address
 
 
Health Information:
 
Rate your health
 
 Your approximate weight in lbs          Weight changes recently 
 
List all important present or past illnesses, injuries or handicaps:
 
Date of last medical examination         
 
Report
 
Your Physician           
 
Address 
 
Are you presently taking medication?
 
What?
 
Have you ever had a severe emotional upset?
 
Explain
 
Have you ever been arrested?
 
Are you willing to sign a release of information form so that your counselor may write for social, psychiatric, or medical reports?
 
Have you recently suffered the loss of someone who was close to you?
 
Explain
 
Have you recently suffered the loss from serious social, business, or other reversals?
 
Explain
 
 
Religious Background:
 
Denominational preference
 
Member?
 
Church Attendance per month
 
Church attended in childhood?
 
Baptized?
 
Religious Background of Spouse (if married)
 
Do you consider yourself a religious person?
 
Do you believe in God?
 
Do you pray to God?
 
Are you saved?
 
How much do you read the Bible?
 
Do you have regular family devotions?
 
Explain recent changes in you religious life, if any
 
 
Personality Information:
 
Have you ever had any psychotherapy or counseling before?
 
If yes, list counselor or therapist and dates:
 
What was the outcome?
 
Choose any of the following words which best describe you now:
Active     Ambitious     Self-Confident     Persistent     Nervous     
Hardworking     Impatient     Impulsive     Moody     Often-Blue
Excitable     Imaginative     Calm     Serious     Easy-Going
Shy     Good-Natured     Introvert     Extrovert     Likeable
Leader     Quiet     Hard-Boiled     Submissive     Lonely
Self-Conscious     Sensitive     Other
 
Have you ever felt people were watching you?
 
Do people's faces ever seem distorted?
 
Do colors ever seem to bright?
 
Are you sometimes unable to judge distance?
 
Have you ever had hallucinations?
 
Are you afraid of being in a car?
 
Do you have problems sleeping?
 
 
Marriage and Family Information:
 
Name of Spouse
 
Address
 
Phone
 
Occupation
 
Your spouse's age
 
Is spouse willing to come for counseling?
 
Have you ever been separated?
 
If so, when? From  To
 
Has either of you ever filed for divorce?
 
If so, when?
 
Date of Marriage
 
Your ages when married: Husband   Wife
 
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:
 
 
Information About Children:
        From
Previous Marriage?      Children's Names                   Age              Gender     Living(Yes or No)   Education in Years       Marital Status
                                 
                                 
                                 
                                 
                                 
                                 
 
If you were reared by someone other that your own parents, briefly explain:
 
 
How many older brothers  sisters  do you have?
How many younger brothers  sisters  do you have?
 
 
Briefly answer the following questions:
 
1. What is the problem you are having?
 
2. What have you done about it?
 
3. What can we do?
 
4. As you see yourself, what kind of person are you? Describe yourself (angry, happy, sad, bitter, etc.)
 
5. What, if anything, do you fear?
 
6. Is there any other information I should know?
 
 
 
What days and times work best for a counseling session?
                                                                
Monday                   Morning     Afternoon     Evening
Tuesday                  Morning     Afternoon     Evening 
Wednesday             Morning     Afternoon     Evening
Thursday                Morning     Afternoon     Evening
Friday                    Morning     Afternoon     Evening
Saturday                Morning     Afternoon     Evening