Personal Data Inventory

Company

This field is for validation purposes and should be left unchanged.

Please complete this inventory carefully and completely.

Who were you referred by?(Required)

Indentification Data

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Email(Required)

Phone(Required)

May we contact you by email?(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Age(Required)

Sex(Required)

Marital Status(Required)

Education: Highest Level Completed(Required)

Other Training

Health Information

Describe your health(Required)

Do you have any chronic conditions?(Required)

List important illnesses and injuries or handicaps(Required)

What is the date of your last medical exam? What was the report?(Required)

What is your physician's name and address?(Required)

Current medication(s) and dosage(Required)

Please include all medicines; prescription and over-the-counter (e.g., laxatives, birth control, aspirin, cold or allergy sprays, diet pills, etc.)

Have you ever used drugs for other than medical purposes?(Required)

Please explain(Required)

Do you drink alcoholic beverages?(Required)

How frequently and how much?(Required)

Do you drink caffeinated drinks?(Required)

How frequently and how much?(Required)

Have you ever seen a psychiatrist or counselor?(Required)

Please explain(Required)

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

Women Only

Have you had any menstrual difficulties?(Required)

Do you experience tension, tendency to cry, or other symptoms prior to your cycle?(Required)

Please explain(Required)

Marriage & Family

Spouse Name(Required)

First Last

Date of Birth(Required)

MM slash DD slash YYYY

Age(Required)

Occupation(Required)

How Long Employed?(Required)

Phone(Required)

Date of Marriage(Required)

MM slash DD slash YYYY

Date of Divorce(Required)

MM slash DD slash YYYY

Length of Dating(Required)

Length of Engagement(Required)

Have either of you been previously married?(Required)

Who was previously married?(Required)

Is your spouse willing to come for counseling?(Required)

Is he/she in favor of your coming?(Required)

Please explain(Required)

How many siblings do you have?(Required)

Your sibling order(Required)

Are your parents living?(Required)

Do they live locally?(Required)

Do you have children?(Required)

Children

Please list your children(Required)

Please click the "+" icon to add more than one child.

Name

Age

Sex

Living (Y/N)

Lives with you (Y/N)

Education in Years

Marital Status

Spiritual Information

Denominational preference(Required)

Religious Background of Spouse(Required)

Church you attend

How often do you attend?(Required)

How often do you attend church per month?(Required)

Do you believe in God?(Required)

Do you pray?(Required)

How often do you read the Bible?(Required)

Are you saved?(Required)

Personality Information

Check any of the following words which best describe you now(Required)

Active

Ambitious

Self-confident

Persistent

Nervous

Hardworking

Impatient

Moody

Kindly

Often-Blue

Excitable

Imaginative

Calm

Serious

Easy Going

Good Natured

Shy

Introvert

Extrovert

Likeable

Leader

Quiet

Hard Boiled

Submissive

Spiritual

Lonely

Self-conscious

Sensitive

Other

If you selected "Other" list here:(Required)

Have you ever felt people were watching you?(Required)

Do you ever have difficulty distinguishing faces?(Required)

Do people’s faces ever seem distorted?(Required)

Do colors ever seem too bright?(Required)

Are you sometimes unable to judge distance?(Required)

Have you ever had hallucinations?(Required)

Are you afraid of being in a car?(Required)

Is your hearing exceptionally good?(Required)

Do you have problems sleeping?(Required)

How many hours of sleep do you average each night?(Required)

Final Questions

What are your struggles? (What brings you here)?(Required)

What have you done about your struggles?(Required)

What are your expectations from counseling?(Required)

Is there any other information we should know?(Required)

We request that you give 24 hours notice for any appointment cancelations. Do you agree?(Required)