Providence Downtown – Roots by the River

Roots by the River Counseling                                Personal Data Inventory       

Personal Identification

Name:____________________________________________________________________________  Birth Date: ________________

Address:_________________________________________________________________________  Zip Code:  __________________

Age: _____________ Sex: ____________  Referred by:________________________________________________________________

Marital Status:  Single___ Engaged ___ Married ___ Separated ___ Divorced ___ Widowed ___

Education (last year completed) _________________________________

E-Mail: ____________________________________________________  Best Contact Phone: ________________________________

Employer: ____________________________________  Position: __________________________  Years: ______________________

Marriage and Family

Spouse: ______________________________________________________________  Birth Date: _____________________________

Age: _________  Occupation: _________________________________ How long employed: _________________________________

Home phone: ____________________________  Work Phone: ________________________________________________________

Date of Marriage:  __________________  Length of Dating: ____________

Give a brief statement of circumstances of meeting and dating:

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Have either of you been previously married? __________________  To whom? ___________________________________________

Have you ever been separated? ________________  Filed for divorce?  ____________

On a scale of 1 to 5, how would you rate your marriage? _______________

Is spouse willing to come for counseling?    NO          YES         Uncertain

Information about Children

Name                       Age              Sex         Where Living                                      Grade

1.

2.

3.

4.

Describe your relationship to your father: __________________________________________________________________________

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Describe your relationship to your mother: _________________________________________________________________________

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Number of sibling(s): ______________________ Your place in sibling order: ___________________

Did you live with anyone other than parents? _______________________________________________________________________

Are your parents living? _______________________  Do they live locally? ________________________________________________

Health

Rate your health (check):      Very Good       Good      Average      Declining      Other: ________________________________________

Weight changes recently:      Lost      Gained

Do you have chronic conditions?  ______________  What: ____________________________________________________________

List important illnesses and injuries or handicaps: ___________________________________________________________________

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Have you ever used drugs for anything other than medical purposes? ______________  If yes, please explain:

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Have you ever been arrested? ___________________________________________________________________________________

Do you drink alcoholic beverages? _______________  If so, how frequently and how much: _________________________________

Do you drink coffee? _______________  How much: _________________________

Other caffeine drinks: _______________ How much: _________________________

Do you smoke? ________________  What: ______________________________  Frequency: ________________________________

Have you ever had interpersonal problems on the job? ______________________________________________________________

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

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Have you ever seen a psychiatrist or counselor? ________________  If yes, please explain: __________________________________

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Spiritual

Church attending: ____________________________________________  Pastor’s Name: ___________________________________

Member (Circle):  Yes  or  No       How long have you been attending with this church fellowship? _____________________________

Church attendance per month (Circle):  0     1     2     3     4     5     6     7     8+

Do you attend a small group or home church? ______________________________________________________________________

Do you believe in God? _________  Do you pray? _________  Would you say that you are a Christian? _________________________

Please explain how you believe one becomes a Christian? _____________________________________________________________

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Have you ever been baptized? ______________  When and by whom? __________________________________________________

How often do you read the Bible? ________________________________________________________________________________

How would describe your relationship with God? ____________________________________________________________________

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Explain any recent changes in your spiritual life? ____________________________________________________________________

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Are you involved in some kind of ministry at your church or elsewhere? _________________________________________________

Do you financially support your church on a regular basis?          Yes          No

Problem Check List (circle any that pertain to you):

Abuse     Adultery     Anger     Anxiety     Apathy     Bitterness     Cheating     Children     Communication     Conflict (fights)

Concentration     Decision making     Depression     Discontent     Drugs     Drunkenness     Eating disorder     Envy     Fatigue     Fear

Financial debt     Forgiveness     Gambling     Gossip     Greed     Guilt     Hatred     Health    Inconsistency    In-laws     Insecurity

Lack of discipline   Laziness     Loneliness     Lust     Lying     Marriage issues     Masturbation     Materialism     Moodiness     Overeating

Overspending     Passivity     Perfectionism     Pornography     Self injury     Selfishness    Self-pity     Sex     Stealing     Sleep    Suicide

Teenage rebellion     Other: ____________________________________________________________________________________

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Briefly answer the following questions:

What circumstances led to your coming here at this point in time? _____________________________________________________

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What have you done about the problem? __________________________________________________________________________

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What are you expectations from counseling? _______________________________________________________________________

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Is there any other information that we should know? ______________________________________________________________

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