The Biblical Counseling Ministry Personal Data Inventory The Biblical Counseling Ministry Personal Data Inventory Personal InformationName First Last Email Date of Birth MM slash DD slash YYYY Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Gender Male Female Marital StatusSingleEngagedMarriedSeparatedDivorcedWidowedEducationSome high schoolHigh schoolSome collegeAssociatesBachelorsMastersDoctorateCell PhoneHome PhoneWork PhoneEmployer Position, Number of Years Marriage and FamilySpouse First Last Spouse's Date of Birth MM slash DD slash YYYY Employer Position, Number of Years Cell PhoneHome PhoneWork PhoneAnniversary MM slash DD slash YYYY Have you ever been separated? No Yes Have you ever filed for divorce? No Yes Have either of you been previously married? No Yes Please list the names and ages of your childrenDescribe your relationship to your father.Describe your relationship to your mother.Number of siblingsDid you live with anyone other than parents/siblings? If so, who? Are your parents living? HealthDescribe your overall health.Do you have any chronic conditions? If so, please list them. List any significant illnesses and/or injuries.Date of Last Medical Exam & any significant findings/results Current medication(s) & dosage Have you ever been arrested? Yes No Do you drink alcoholic beverages? Yes No If so, how frequently?Do you drink coffee? Yes No If so, how frequently?Do you drink caffeinated beverages? Yes No If so, how frequently?Do you smoke? Yes No If so, how frequently?Have you ever had a severe emotional upset? If so, please explain.Have you ever seen a psychiatrist or counselor? If so, 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? Yes No N/A Problem ChecklistAngerAnxietyApathyAppetiteBitternessChange in lifestyleChildrenCommunicationConflict (fights)DeceptionDecision MakingDepressionDrunkennessEnvyFearFinancesGluttonyGuiltHealthHomosexualityImpotenceIn-lawsLonelinessLustMemoryMoodinessPerfectionismRebellionSexSleepMarital difficultiesOtherSpiritualDo you attend a church? If so, please list the name of the church Denomination of church attending: Are you a member of this church you are attending? Yes No N/A Have you ever been baptized? Yes No How often do you read the Bible? Never Occasionally Often Daily Have there been any recent changes in your religious life? If so, explain.Women OnlyHave you had any recent menstral difficulties? If you experience tension, tendency to cry, other symptoms prior or during your cycle, please explain:Is your husband willing to come for counseling? Yes No N/A Is he in favor of you coming to counseling? Yes No N/A If no, please explain:Briefly answer the following questions:What is your problem? For what reason are you seeking counseling?What have you done about the problem?What are your expectations from counseling?Is there any other information that we should know?
