PERSONAL DATA INFORMATION FORM
This form must be completed in full before the first counseling session. All information is confidential.
Date received in office: _______
PERSONAL IDENTIFICATION DATA
Name ______________________________________ Phone_________________________
Address __________________________________ City___________ Zip____________
Occupation ______________________________ Business Phone _______________________
Employment Status: (circle one) Full-time Part-time Unemployed Homemaker Student
Sex ________ Birth Date _________ Age ________
Referred here by _____________________________________
HEALTH INFORMATION
Rate your health (circle) Very Good Good Average Declining Other
Height______________ Your approximate weight________lbs
Weight Changes recently: Same ________ Lost __________ Gained __________
List all important present/past illnesses/injuries/handicaps ________________________________
_________________________________________________________________________________
Date of last medical examination _________________ Report__________________
Are you presently under a physician’s care? Yes _______ No __________
Your physician_____________________
Are you presently taking medication? Yes ______ No ____
What for?________________________________________
Have you used drugs for other than medical purposes? Yes__________ No________
Have you ever been arrested? Yes___________ No______________
Have you recently suffered the loss of someone who was close to you? Yes____________ No ________
Explain _________________________________________________________________________
EDUCATION
Education completed _______grade
Other training (list type and years, include any degrees) _______________________________
_______________________________________________________________________________
MARRIAGE AND FAMILY INFORMATION
Marital Status Single______ Going Steady______ Engaged_________ Married____________
Separated___________ Divorced________ Widowed________
Name of spouse/partner ____________________ Address ______________________________
Phone _______________ Occupation ________________ Business Phone________________
Your spouse/partner age _____ Education (in years) _______ Religion __________
Is spouse/partner willing to come for counseling? Yes ________ No______ Uncertain ______
Have you ever been separated? Yes ________ No _______ When? From ____ to ______
Have either of you ever filed for divorce? Yes_____ No ______ When?
Date of Marriage __________ Your ages when married: Husband ________ Wife_______
How long did you know your spouse before marriage? _______________________
Length of steady dating with spouse ___________ Length of engagement ___________
Give brief information about any previous marriages: _______________________
Information about family/children
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(indicate with an asterisk (*) if child is from previous marriage/indict with a circle if child was miscarried or still born)
Have you ever had an abortion? Yes _______ No ________
Has any of your children been miscarried or still born? Yes ______ No __________
If you were reared by anyone other than your own parents, briefly explain: _______________
_______________________________________________________________________________
How many older brothers____ sisters ______ do you have?
How many younger brothers _____ sisters ____ do you have?
Has there been any deaths in the family during the last year? Yes ______ No ______
Who/When: _____________________________________________________________________
RELIGIOUS BACKGROUND
Denomination preference: _________________________ Member of ________Church
Church attendance per month (circle): 0 1 2 3 4 5 6 7 8 9 10+
Church attended in childhood: ___________________ Baptized? Yes ________ No____
Religious Background of spouse (if married): ___________________________
Baptized? Yes___ No____
Do you consider yourself a religious person? Yes _______ No _______ Uncertain _______
Do you believe in God? Yes _____ No _______ Uncertain_________
Do you believe Satan exists? Yes________ No_____________ Uncertain_______________
Have you ever “dabbled” with the “Occult” – Séances, devil worship, witchcraft? Yes______ No__________ Uncertain____________
Do you pray to God? Never_______ Occasionally ________ Often_________
Would you say you are a Christian? Yes_____ No___________ or would you say you are still in the process of becoming a Christian?_______________________
How often do you read the Bible? Never______ Occasionally ________ Often ______________
Do you have regular devotions? Yes ___________ No______ Not sure what you mean__________
Explain recent changes in your religious life, if any _______________________________________
_________________________________________________________________________________
PERSONALITY INFORMATION
Have you ever had any psychotherapy or counseling before? Yes_______ No_________
If yes, list counselor or therapist and dates: ____________________________________________
_______________________________________________________________________________
What was the outcome? ___________________________________________________________
________________________________________________________________________________
As you see yourself, what kind of person are you? Describe yourself _________________________
_________________________________________________________________________________
_________________________________________________________________________________
_____________________________________________________________________________
What, if any, do you fear? Yes______ No_______ Explain
__________________________________________________________________________________
Is there any other information that would help us help you?
Have you recently suffered a loss from serious social, business, or other reversals, etc?
Circle any/all of the following words that best describe you now:
activeambitious self-confident persistent hardworking calm
imaginative serious easy-going good-natured quiet leader
hard-boiled submissive sensitive introvert extrovert likeable
Other ____________________________________________________________
FAMILY AND CHILDHOOD INFORMATION:
If you were reared by anyone other than your own parents, briefly explain: __________________________________________________________________________
How many older brothers _____ sisters _____ do you have?
How many younger brothers _____ sisters _____ do you have?
Are you on good terms with your Mother _____ Father _____ Brother _____ Sisters? _____
List the people that you hate or are extremely angry with, and the reasons: ____________________________________________________________________________
____________________________________________________________________________
What kind of home did you grow up in? (Check all that apply)
_____ Traditional (Father, Mother, Kids)
_____ Authorization (Father or Mother made all the rules without discussion.)
Would not allow for other opinions.
_____ Divorced (Who did you live with? _____ Mom _____ Dad Other ____________________)
_____ Alcoholic ( _____ Skid row _____ Functional, but affected _____ Dysfunctional effect on family)
_____ Drug Affected ( _____ Cocaine _____ Heroin _____ Marijuana _____Other ________________)
_____ Perfectionist (Everything had to be done just right to please _____ Mom _____ Dad _____Both
_____ Critical (One or both parents could only remark about the negatives.
Little praise for good things)
_____ Affectionate (_____ Demonstrative with hugs, kisses, etc. ______ Affection there, but not openly shown.)
Emotionally (_____Crying allowed, but controlled. _____ Anger, screaming freely allowed).
_____ Repressed (_____ Emotions not allowed to show. _____ Parents showed emotion, but kids not allowed to do so).
_____ Religious (_____ In name only _____ Strict, negative _____ Hypocritical Genuine Happy Experience)
_____ Step-family (_____Which of parents remarried? ______________ Had to live with step-brothers or step-sisters)
_____ Abusive (In what way? _____ Sexual _____ Physical Beatings _____ Emotional _____ Other: _____________________________)
What kind of home did your Father grow up in? _____ Traditional (Father, Mother, Kids)
_____ Authoritarian (Father or Mother made all the rules without discussion
Would not allow for other opinions.
_____ Divorced (Who did you live with? _____ Mom _____ Dad Other _________________)
Alcoholic (_____ Skid row _____ Functional, but affected _____ Dysfunctional effect on family)
_____ Drug Affected ( _____ Cocaine _____ Heroine _____ Marijuana ______ Other ______________)
_____ Perfectionist (Everything had to be done just right to please _____ Mom _____ Dad _____ Both)
_____ Critical (One or both parents could only remark about the negatives. Little praise for good things)
_____ Affectionate (____ Demonstrative with hugs, kisses, etc. _____ Affection there, but not openly shown)
_____ Emotional (_____ Crying allowed, but controlled, _____ Anger, screaming freely allowed)
_____ Repressed (_____ Emotions not allowed to show. _____ Parents showed emotion, but kids not allowed to do so.)
_____ Religious (_____ In name only _____ Strict, negative _____ Hypocritical _____ Genuine Happy Experience).
_____ Step-family (_____ Which of parents remarried? ___________________ Had to live with step-brothers or step-sisters)
_____Abusive (In what way? _____ Sexual _____Physical Beatings _____ Emotional _____ Other: _____________________________________
What kind of home of home did your mother grow up in? _____ Traditional (Father, Mother, Kids)
_____ Authoritarian (Father or Mother made all the rules without discussion
Would not allow for other opinions.
_____ Divorced (Who did you live with? _____ Mom _____ Dad Other _________________)
Alcoholic (_____ Skid row _____ Functional, but affected _____ Dysfunctional effect on family)
_____ Drug Affected ( _____ Cocaine _____ Heroine _____ Marijuana ______ Other ______________)
_____ Perfectionist (Everything had to be done just right to please _____ Mom _____ Dad _____ Both)
_____ Critical (One or both parents could only remark about the negatives. Little praise for good things)
_____ Affectionate (____ Demonstrative with hugs, kisses, etc. _____ Affection there, but not openly shown)
_____ Emotional (_____ Crying allowed, but controlled, _____ Anger, screaming freely allowed)
_____ Repressed (_____ Emotions not allowed to show. _____ Parents showed emotion, but kids not allowed to do so.)
_____ Religious (_____ In name only _____ Strict, negative _____ Hypocritical _____ Genuine Happy Experience).
_____ Step-family (_____ Which of parents remarried? ___________________ Had to live with step-brothers or step-sisters)
_____Abusive (In what way? _____ Sexual _____Physical Beatings _____ Emotional _____ Other: _____________________________________
Would you characterize your Father as: (Circle the appropriate words)
Godly Ethical Hypocritical Strict Angry Unreasonable Abusive
Irresponsible Cruel Uneducated Proud Embarrassing Active Active Ambitious
Self-confident Persistent Nervous Hardworking Impatient Impulsive
Moody Often-blue Excitable Imaginative Calm Serious Easy-going Shy
Good-natured Introvert Extravert Likeable Leader Quiet boiled Hard-boiled
Submissive Lonely Self-conscious Sensitive Humorous Sloppy Well-groomed
Self-disciple Whiner Selfish Lots of friends Failure Success
Other ______________________________
Would you characterize your Mother as:
Godly Ethical Hypocritical Strict Angry Unreasonable Abusive
Irresponsible Cruel Uneducated Proud Embarrassing Active Active Ambitious
Self-confident Persistent Nervous Hardworking Impatient Impulsive
Moody Often-blue Excitable Imaginative Calm Serious Easy-going Shy
Good-natured Introvert Extravert Likeable Leader Quiet boiled Hard-boiled
Submissive Lonely Self-conscious Sensitive Humorous Sloppy Well-groomed
Self-disciple Whiner Selfish Lots of friends Failure Success
Other ______________________________
Where did you grow up? _____ Urban Area _____ Suburban Area _____ Small Town _____ Rural _____ Farm City, State _____________________________ Population ________________________
What was your family’s economic situation when you were a child?
_____ Extremely poor _____ Poor _____Lower Middle Income _____ Middle Income _____Higher Middle Income _____Wealthy _____ Extremely wealthy
Were you ever sexually abused by anyone? _____ No _____ Yes
(Please detail: _____ Were you abused by a relative? _____ Were you abused by a stranger? _____ A neighbor? How old were you at the time? _____ Was the person who abused you ever prosecuted? ______)
What was your happiest memory as a child? _____________________________________________________________________________
_____________________________________________________________________________
What was your unhappiest memory as a child? _____________________________________________________________________________
_____________________________________________________________________________
Did you experience a major trauma when you were a child? Detail:
_____ At Home ________________________________________________________________
_____ At School _______________________________________________________________
_____ At Neighbor’s Home _______________________________________________________
_____ At Relative’s Home ________________________________________________________
_____ Other ___________________________________________________________________
TELEVISION & ENTERTAINMENT
How much television do you watch each day? _________ hrs.
List your favorite programs: ________________________________________________________
What is your favorite type of music? _________________________________________________
List your favorite entertainers: ______________________________________________________
_________________________________________________________________________________
BIO-PSYCHOLOGICAL INFORMATION
Have you ever felt people were watching you? Yes _____ No _______
Have you ever felt people were watching you? Yes ______ No _______
Do people’s faces ever seem distorted? Yes_______ No _______
Do you ever have difficulty distinguishing faces? Yes _______ No ______
Do colors seem too bright? ______ Too dull? _________
Are you sometimes unable to judge distance? Yes_____ No______
Have you ever had hallucinations? Yes_______ No_______
Are you afraid of being in a car? Yes _____ No _____
Is your hearing exceptionally good? Yes______ No________
Do you have problems sleeping? Yes______ No________
PERSONAL BEHAVIORAL HABITS
- Do you think coffee or other caffenated drinks? Yes _____ No _____ How much per day?
- Do you smoke? Yes _____ No _____ How much? ____________________________
- Do you explode when you get angry? Yes _____ No _____
- Do you withdraw when you get angry or hurt? Yes _____ No _____
- Do you frequently argue with significant other people? Yes _____ No _____
WOMEN ONLY
Have you had any menstrual difficulties? ______________________________________________
Do you experience tension, tendency to cry, other symptoms prior to your cycle? Please explain: ________________________________________________________________________________
________________________________________________________________________________
Is your husband willing to come for counseling?
________________________________________________________________________________
Is he in favor of your coming? _______ If no, explain ____________________________________
________________________________________________________________________________
BRIEFLY ANSWER THE FOLLOWING QUESTIONS
1. What problem brings you here? ________________________________________________
________________________________________________________________________________
2. What have you done about it? ____________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
3. Have you ever had any counseling before? Yes _______ No _______
If so, what was the outcome? __________________________________________________
4. What can we do? (What are your expectations in coming here?) ________________________
_________________________________________________________________________________
_________________________________________________________________________________
5. Is there any other information we should know? _____________________________________
________________________________________________________________________________
________________________________________________________________________________
PROBLEM CHECK LIST: (Check those which are current)
_____ Anger _____ Envy _____ Appetite
_____ Anxiety _____ Fear _____ Memory
_____ Apathy _____Gluttony _____Moodiness
_____ Bitterness _____ Guilt _____ Rebellion
_____ Children _____ Homosexuality _____Sleep
_____ Depression _____Impotence _____ Wife Abusive
_____Deception _____ In-laws _____ A Vice
Circle any/all of the following words that best describe what you are feeling right now:
nightmares sorrowful grieving broken-hearted self-pity rejected despair
dejected hopelessness helplessness suicidal thoughts inner hurts heaviness anxiety
phobia stress torment doubt untrusting emptiness nervous
impatient impulsive often blue shy lonely shame
fear of man fear of death anger loneliness low self-esteem
moody condemnation self-conscious
Other ________________________________________________
