Bay Area Ministers of Reconciliation
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Personal Data Inventory

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  • Personal Data Inventory

Personal Data Inventory Online Form

Personal Identification

Name
MM slash DD slash YYYY
Sex
Address
Marital Status
Education
Emergency Contact

Marriage & Family:

MM slash DD slash YYYY
Spouses Name
Have either of you been previously married
Have you ever been separated
Filed for divorce

Children

You can add multiple children by selecting the (+) button at the end of each row.
Information about children
Name
Age
Sex
Living w/ you?
Grade
Step child (Y/N)
 

Your Childhood

Did you live with anyone other than parents as a child?
Are your biological parents living?
Do your biological parents live locally

Health

Do you have any chronic conditions?
List any important illnesses or handicaps
Illness or handicaps
 
You can add multiple illnesses or handicaps by selecting the (+) button at the end of each row.

Substance Use & Lifestyle

Have you ever been arrested?
Have you ever used drugs for anything other than medical purposes?
Do you drink alcoholic beverages?
Do you drink coffee?
Do you drink other caffeinated drinks?
Do you smoke?
Have you ever had interpersonal problems on the job?
Have you ever had a severe emotional upset?
Have you ever seen a psychiatrist or counselor?
Are you a Christian?
Do you attend church?
Church attendance per month
Name of pastor or deacon over you
Have you been baptized?
How often do you read your Bible

Problem Check List

Select all that apply
Problems Set 1
Problems Set 2
Problems Set 3
List any other problems you are experiencing
You can add additional problems or issues by selecting the (+) button at the end of each row.

Briefly answer the following questions

Personal Inventory

Rate yourself on each of the following traits.
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Are there any other attributes you would like to comment on?

Spiritual Convictions Questionnaire

This field is for validation purposes and should be left unchanged.

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