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

 

Name	Age	Sex	Living Yes/No	Occupation	Marital Status

 

(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

 

1. Do you think coffee or other caffenated drinks? Yes _____ No _____ How much per day?
2. Do you smoke? Yes _____  No _____  How much? ____________________________
3. Do you explode when you get angry? Yes _____ No _____
4. Do you withdraw when you get angry or hurt? Yes _____ No _____
5. 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 ________________________________________________