BIGELOW CHURCH PERSONAL DATA INVENTORY
(Please completely fill out this form and make it available to your counselor before your first counseling session.) Name Address (Street) Sex Age Date of Birth Phone Education/Training Phone (City) (State) (Zip)
Occupation Business Address Referred for counseling by PERSONAL HISTORY Parents: Father: Mother: Name
Age(if living)
Occupation
Marital Status
Guardian Name (if applicable) Reason for Guardianship Siblings: Name Age
Relation to you Date Relationship to Marital Status
More than five? Yes No Indicate which might have applied during your childhood and/or adolescence: School problems Family problems Medical problems Drug/Alcohol abuse problems Social problems Legal problems Please explain:
OCCUPATIONAL HISTORY What jobs have you held in the past?
Does your present work satisfy you? If not, please explain.
2 MARITAL STATUS Marital Status: Single Engaged Married Remarried Your Present Marriage (if applicable) Spouse’s name Spouse’s religious background Separated Divorced Widowed
Age
Occupation Education
Date of marriage Have you ever been separated from your present spouse? If yes, please specify when: 1) to 2) to Children Name-Relationship-Living at Home-Age-Marital Status-Occupation (son, step daughter, etc.)
Your Previous Marriages (if applicable) Date to to
Children from this marriage
Spouse’s Previous Marriages (if applicable) Date Children from this marriage to to RELIGIOUS BACKGROUNDS Denominational preference Church presently attended (name and address): Phone Pastor Do you believe in God? Yes__ No__ Do you consider yourself “Saved”? Yes__ No__ Not sure what you mean__ If you were to die and stand before God and He asked you why He should permit you to enter Heaven, how might you respond? Permission to consult with pastor: Yes__ No__
3 MEDICAL HISTORY Have you had any of the following physical problems? Please check. Heart problems Sensory distortion__ Head injury\concussion__ Seizures__ Parkinson’s disease__ Episodic disorientation__ Impotence__ Physical change__ Changes in consciousness__ Dizziness__ High Blood Pressure__ Bulimia__ Anorexia__ Change in sex drive__ Fatigue_ Memory problems__ Amnesia__ Personality change__ Déjà vu__ Tremors__ Cancer__ Incoordination__ Menstrual irregularities__ Hallucinations__ Stroke__ Brain tumor__ Blackouts__ Weight change__ Thyroid dysfunction__ Diabetes__ Headaches__ Speech problems__
List previous surgeries (those which require anesthesia)
List all prescription and over-the-counter medications: Include diet pills, laxatives, birth control pills, cold and allergy medications, aspirin.
Have you sought and received counseling of any type? Yes__ No__ If yes, when? With whom? What was the outcome?
How many hours of sleep do you average each night? Have there been any changes? Is this sleep restful? Have you or others notices any changes in your personality (anger, mood swings, withdrawal), thinking and memory, or work habits?
As you see yourself, what kind of person are you? (describe yourself)
4 State in your own words the nature of the main problem(s) that bring you for counseling?
When did your problems begin? Please specify a date if possible.
Please describe any significant events occurring at that time?
What have you done to try to resolve your problem(s)?
What would you like us to do for you? What kind of help do you want from us?
Is there any other information we should know?