General Guidelines for Every Session

Biblical Soul-Care Ministry

Personal Data Inventory for Men

Please complete this inventory carefullyand as honestly as you can.

Personal Identification

Name: ______Birth Date: ______

Address: ______

Post Code: ______Age: ______Referred by: ______

Education (last year completed): ______

Home Phone: ______Work Phone: ______

Mobile Phone:______Email: ______

Occupation ______Employer: ______

Years with this employer: ______

Marriage and Family Details

Marital Status(cicle): Married Single Engaged Separated Divorced Widowed De-Facto

Spouse’s details: ______Birth Date: ______

Age: ______Occupation: ______How Long Employed: ______

Date of Marriage: ______Length of Dating: ______

Give a brief statement of circumstances of meeting and dating:

______

Have youbeen marriedpreviously? Y / N Was your spouse previously married? Y / N

When and how did it/they end? ______

Describe your relationship to your spouse: ______

______

Describe your relationship to your children: ______

______

______
Information about Children:

Name:Age: Sex:Living Y/NYear Education: Step-Child Y/N

______

Describe your relationship to your father: ______

______

Describe your relationship to your mother: ______

______

Number of siblings: ___ Your sibling orderPlease circle below where you fit in your family:

Oldest…………………………….…………………………………Youngest

1 2 3 4 5 6

Brother Brother Brother Brother Brother Brother

Sister Sister Sister Sister Sister Sister

Me Me Me Me Me Me

Was yours a blended family? Y / N Are all your siblings still living Y / N

Are your parents living? Dad Y / N Mum Y / NWhere do they live? ______

Did you live with anyone other than parents?______

Health

Describe your health: ______

Do you have any chronic conditions? Y / N If yes, 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 use addictive substances? Y / N If so, whatand how frequently? ______

Do you drink energy/caffeinated drinks? Y / N If yes, what are they? ______

How many per day? ______

Do you smoke? Y / N If yes, what? ______Frequency: ______

Have you ever had interpersonal problems on the job? Y / N If yes, please explain ______

Have you ever had a severe emotional upset? Y / N If yes, please explain ______

______

Have you ever seen a psychiatrist or counsellor? Y / N If yes, please explain______

______

Are you willing to sign a release of information form so that your advisor may write for social, psychiatric, or other medical records? Y / N

Spiritual

Would you say that you are a Christian? Y / N or investigating? Y / N

Do you believe in God?Y / NDo you pray? Y / N

How often do you read the Bible (circle) Never Monthly Weekly Daily

Do you go to church? Y / N

If yes, church currently attending: ______Member: Y / N

Church attendance per month (circle): WeeklyBi-weeklyMonthlyNever

Denominational preference: ______

Have you ever been baptised? Y / N If yes, what year and where?______

Briefly describe the issue for which you wish to see us: ______

______

Thank you for taking the time to fill in this questionnaire—it will assistus greatly in helping you. Please return these pages to us either by regular mail or email. We will then contact you.