Personal Data Inventory

Name *

First Name

Last Name

Phone *

Country

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Birth Date *

MM

DD

YYYY

Sex *

Male

Female

Name of Spouse

First Name

Last Name

Spouse’s Phone

Country

(###)

###

####

Business Phone

Country

(###)

###

####

Does your spouse know you are coming for counseling?

Yes

No

Is your spouse willing to come to counseling?

Yes

No

Uncertain

Have you ever been separated?

Yes

No

Date of Separation

MM

DD

YYYY

End Date of Separation

MM

DD

YYYY

Wedding Date

MM

DD

YYYY

Have you received counseling before? *

Yes

No

Check any of the following words which best describe you now *

Active

Ambitious

Self-Confident

Persistent

Anxious

Hard Working

Impatient

Impulsive

Moody

Often Sad

Excitable

Imaginative

Calm

Serious

Easy Going

Shy

Fearful

Introvert

Extrovert

Likable

Leader

Quiet

Inflexible

Submissive

Sensitive

Lonely

Self-Conscious

Bitter

Angry

Have you ever felt that people were watching you? *

Yes

No

Have you ever had difficulty recognizing faces? *

Yes

No

Have you ever been unable to judge distances? *

Yes

No

Have you ever had visual hallucinations? *

Yes

No

Have you ever had auditory hallucinations? *

Yes

No

Have you ever been arrested? *

Yes

No

What time do you typically go to sleep at night? *

Hour

Minute

Second

AM PM

What time do you typically wake up in the morning? *

Hour

Minute

Second

AM PM

Rate your health.

Very Good

Good

Average

Declining

Date of Last Medical Examination *

Approximate if unsure.

MM

DD

YYYY

Have you used medication for recreational purposes? *

Yes

No

Have you been baptized?

Yes

No

Do you believe in God?

Yes

No

Uncertain

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

Uncertain

Does your family regularly read the Bible and pray together?

Yes

No