The Bridge Bible Fellowship
Biblical Counseling

Personal Data Inventory

Personal Identification

Name: ______Birth Date: ______

Address: ______Zip Code: ______

Age: ______Sex: ______Referred By: ______

Marital Status: Single: ______Engaged: ______Married: ______Separated: ______

Divorced: ______Widowed: ______

Education (last year completed): ______

Home Phone: ______Work Phone: ______Cell Phone: ______

Employer: ______Position: ______

Years: ______

Marriage and Family

Spouse: ______Birth Date: ______

Age: ______Occupation: ______How Long Employed: ______

Home Phone: ______Work Phone: ______Cell Phone: ______

Date of Marriage: ______Length of Dating: ______

Give a brief statement of circumstances of meeting and dating: ______

______

Have either of you been previously married: ______To Whom: ______

Have you ever been separated: ______Filed for divorce: ______

Information about Children:

Name:Age: Sex:Living:Year Ed.:Step-Child:

______

______

______

Describe relationship to your father: ______

______

Describe relationship to your mother: ______

______

Number of sibling(s): ______Your sibling order: ______

Did you live with anyone other than parents: ______

______

Are your parents living: ______Do they live locally: ______

Health

Describe your health: ______

Do you have any chronic conditions: ______What: ______

List important illnesses and injuries or handicaps: ______

______

Date of last medical exam: ______Report: ______

Physician’s name and address: ______

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: ______

Do you drink alcoholic beverages: ______If so, how frequently and how much: ______

______

Do you drink coffee: ______How much: ______Other caffeine drinks: ______

______How much: ______

Do you smoke: ______What: ______Frequency: ______

Have you ever had interpersonal problems on the job: ______

______

Have you ever had a severe emotional upset: ______If yes, please explain: ______

______

Have you ever seen a psychiatrist or counselor: ______If yes, please explain: ______

______

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

Spiritual

Denominational preference: ______

Church attending: ______Member: ______

Church attendance per month (circle): 0 1 2 3 4 5 6 7 8+

Do you believe in God: ______Do you pray: _____ Would you say that you are a Christian: ______,

Or still in the process of becoming a Christian: ______

Have you ever been baptized: ______

How often do you read the Bible: Never: ______Occasionally: ______Often: ______Daily: ______

Explain any recent changes in your religious life: ______

______

Women Only

Have you had any menstrual difficulties: ______If you experience tension, tendency to cry, other symptoms prior to your cycle, please explain: ______

Is you husband willing to come for counseling: ______

Is he in favor of your coming: ______If no, please explain: ______

______

Problem Check List

_____Anger / _____Depression / _____Loneliness
_____Anxiety / _____Drunkenness / _____Lust
_____Apathy / _____Envy / _____Memory
_____Appetite / _____Fear / _____Moodiness
_____Bitterness / _____Finances / ____Perfectionism
_____Change in lifestyle / _____Gluttony / _____Rebellion
_____Children / _____Guilt / _____Sex
_____Communication / _____Health / _____Sleep
_____Conflict (fights) / _____Homosexuality / _____Wife abuse
_____Deception / _____Impotence / _____A Vice
_____ Decision Making / _____In-laws / _____Other

Briefly Answer The Following Questions

  1. What is your problem (what brings you here)?
  1. What have you done about the problem?
  1. What are your expectations from counseling?
  1. Is there any other information that we should know?

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