Biblical Counseling

INDENTIFICATION

* Full Name

* Address

* City

* State

* Zip Code

* Home Phone

* Cell Phone

* Email

Job Title

Work Phone

* Gender

* Birthdate (MM/DD/YY)

* Age

* Marital Status

* Education (last degree completed)

Other training

* With whom do you currently live?

* Referred here by

* Are you sure you have the time to devote to the counseling process?

HEALTH INFORMATION

* Rate your health:

* Weight changes in the last 12 months

* Do you have trouble falling or staying asleep or sleeping too much? If yes, please explain:

* Have you experienced any hearing loss? If yes, please explain:

* List all important present or past illnesses, injuries, or handicaps:

* Date and outcome of last medical examination

* Your Physician

* Physician's phone number

* Are you presently taking any medication? If yes, please list and describe:

* Have you ever used drugs for reasons other than medical? If yes, please explain:

SOCIAL/EMOTIONAL INFORMATION

* Have you ever had a severe emotional upset? If yes, please explain:

* Have you ever been arrested?

* Have you recently suffered the loss of someone who what close to you? If yes, please explain:

* Have you recently suffered the loss from serious social, business, or other reversals? If yes, please explain:

RELIGIOUS INFORMATION

* Where do you attend church?

* How long have you been going there?

* Are you a member?

* Attendance per month

* Did you attend church as a child? If yes, list name of church

* Have you been baptized?

How old were you?

Religious background of spouse (if married)

* Do you believe in God?

* Do you pray to God?

* Are you saved?

If yes, please describe your conversion experience.

* Do you read the Bible?

If married, do you have regular family devotions?

* Are you connected to other believers in a smaller group of any kind in a church? If yes, please specify:

* Have there been any changes in your religious life? If yes, please describe:

* Have you held any positions in your church? If yes, please list:

* Have you ever had a time in your life when you stopped walking with the Lord? If yes, please describe:

PERSONALITY INFORMATION

* Have you ever had psychotherapy or counseling before? If yes, please list counselor/therapist and approximate dates:

What was the outcome?

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

active

ambitious

self-confident

persistent

nervous

hardworking

impatient

impulsive

moody

often blue

excitable

imaginative

calm

serious

easy-going

shy

good-natured

introverted

extroverted

likeable

leader

quiet

tough

submissive

self-conscious

lonely

sensitive

other

* What do you do in your spare time?

MARRIAGE AND FAMILY INFORMATION

Name of spouse (if applicable)

Address of spouse (if other than at home)

Phone Number

Spouse's age

Job Title

Employer (name and field)

Education (last degree completed)

Is your spouse willing to come for counseling?

Does your spouse support your decision to be counseled?

If not, please explain:

Has either of you ever filed for divorce?

If yes, when?

Date of Marriage:

Your age when married:

Spouse's age when married:

How long did you know your spouse before you were married?

Length of steady dating with spouse:

Length of engagement:

Give brief information about any previous marriages:

Information about children:

Name

Age

Gender

Living?

Child from previous marriage?

Education

Married?

Name

Age

Gender

Living?

Child from previous marriage?

Education

Married?

Name

Age

Gender

Living?

Child from previous marriage?

Education

Married?

Name

Age

Gender

Living?

Child from previous marriage?

Education

Married?

If you were reared by anyone other than your own parents, briefly explain:

* How many older brothers do you have?

* How many older sisters do you have?

* How many younger brothers do you have?

* How many younger sisters do you have?

BRIEFLY ANSWER THE FOLLOWING QUESTIONS:

* 1. What do you think/feel is your problem? In other words, what brings you here?

* 2. What have you done about this problem?

* 3. What can we do? What are your expectations from counseling?

* 4. With respect to counseling, what fears do you have?

5. Is there any other information we should know?

Please rate the intensity (on a scale of 1-10, 10 being high) of any of the following that you think may be a problem for you at this time:

Addiction to Alcohol

Addiction to Computer

Addiction to Drugs

Addiction to Sex

Addiction to Smoking

Anger

Anxiety/Worry

Apathy

Bitterness

Change in Lifestyle

Children

Communication

Deception

Depression

Eating Problems

Anorexia

Bulimia

Gluttony

Envy

Fear

Guilt

Health

Homosexuality

Honesty

Impotence

In-laws

Loneliness

Loss of Hope

Memory

Money

Moodiness

Perfectionism

Priorities

Rebellion

Self-injury

Sex

Sleep

Spouse abuses me

Stress

Time Management

* Have you ever experienced interpersonal problems at work?

If yes, please describe:

* What is your preferred learning style? (tapes, videos, books, etc)

SPIRITUAL CONVICTIONS

Please finish the following with two or three sentences each:

* 1. The gospel is: (give a brief summary of your understanding of the gospel message)

* 2. I know that I am (or am not) a Christian because:

* 3a. What place of authority does the Bible have in your life? Is it authoritative?

* 3b. What do you believe about the inerrancy of Scripture?

* 3c. What do you believe about the sufficiency of Scripture?

* 4. Sin is:

* 5. My chief sins are:

* 6. When I sin, I (describe how you handle sin, what you feel when you sin, what you do after you sin):

* 7. I pray (when, how, why, what for, etc.):

* 8. My chief goals in life are:

* 9. I am promoting my spiritual growth (and, if married or dating, the spiritual growth of my spouse or boyfriend/girlfriend) by:

10. (If married or dating) My spouse (or boyfriend/girlfriend) and I differ in spiritual matters (explain when, how, over what, etc.):

* 11. The changes I would like to make in my own spiritual life are:

* With whom do you currently live?

Biblical Counseling - Personal Data Inventory