Counseling for Emotional Wounds
 

Personal Data Inventory

Y Home Y Family Care Counseling Y Telephone Counseling Y  Credentials  Y Personal Data Inventory 
Y What is Temperament? Y Theophostic Ministry® Y Creation Therapy Y Counseling Fees

 

Family Care Counseling

Personal Data Inventory

Instructions:  This confidential information form is for the use of your counselor.  Please complete it as
carefully as you can.  If both husband and wife are coming for counseling, each should fill out a form.

IDENTIFICATION DATA:     Today’s Date:

Name:

Address:

City:  State:    Zip Code: 

Email:

Home Phone:   Work Phone:

Cell:   Pager: 

Sex:   Birth date:  Age:  Height: 

MARRIAGE INFORMATION:  If never married, check and omit this section.

Marital Status: (check)  SINGLE GOING STEADYENGAGEDMARRIED

Name of Spouse:

HOW DID YOU HEAR ABOUT OUR COUNSELING?

Are you presently taking medication?  Yes:No: What:

Have you ever had a severe emotional upset?  Yes: No: When:

PERSONALITY INFORMATION:

Have you ever had counseling before?  No: Yes:When:

Number of Sessions:

INFORMATION ABOUT CHILDREN:

NAME                                          AGE      SEX      LIVING  EDUCATION      MARITAL STATUS

                            

                            

                            

                            

                            

What is your presenting problem?

Y Home Y Family Care Counseling Y Telephone Counseling Y  Credentials Y Personal Data Inventory 
Y What is Temperament?  Y Theophostic Ministry® Y Creation Therapy Y Counseling Fees