Personal Data Inventory Online Form Personal IdentificationName First Last PhoneAlternate PhoneEmail Date of Birth MM slash DD slash YYYY Age Sex Male Female Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Marital Status Single Engaged Married Separated Divorced Widowed How long have you been single? How long have you been engaged? How long have you been separated? How long have you been divorced? How long have you been widowed? Education High School Diploma / G.E.D. Community College or 2 Year School Undergraduate Graduate (Masters, PhD) Employer Position Years: Emergency Contact First Last Emergency Contact Phone NumberMarriage & Family:Date of Marriage MM slash DD slash YYYY Length of dating before marriage Spouses Name First Last Spouses Age Spouses Occupation How long employed Spouses Alternate PhoneSpouses PhoneGive brief statement of circumstances of meeting and dating:Have either of you been previously married Yes No Number of times (Him)Number of times (Her)Have you ever been separated Yes No Filed for divorce Yes No ChildrenYou can add multiple children by selecting the (+) button at the end of each row.Information about childrenNameAgeSexLiving w/ you?GradeStep child (Y/N) Add RemoveYour ChildhoodNumber of siblingsYour sibling orderDid you live with anyone other than parents as a child? Yes No Are your biological parents living? Yes No Do your biological parents live locally Yes No Describe your relationship with your biological Father:Describe your relationship with your biological Mother:HealthDescribe your healthDo you have any chronic conditions? Yes No What chronic conditions List any important illnesses or handicapsIllness or handicaps Add RemoveYou can add multiple illnesses or handicaps by selecting the (+) button at the end of each row.Substance Use & LifestyleHave you ever been arrested? Yes No If "Yes," explain:Have you ever used drugs for anything other than medical purposes? Yes No If "Yes," explain:Do you drink alcoholic beverages? Yes No How frequently and how much? Do you drink coffee? Yes No How frequently and how much? Do you drink other caffeinated drinks? Yes No How frequently and how much? Do you smoke? Yes No How frequently and how much? Have you ever had interpersonal problems on the job? Yes No If "Yes," explain:Have you ever had a severe emotional upset? Yes No If "Yes," explain:Have you ever seen a psychiatrist or counselor? Yes No If "Yes," explain:Are you a Christian? Yes No Do you attend church? Yes No Church attendance per month 1-4 days per month 5-8 days per month 8 or more days per month Name of church attending: Name of pastor or deacon over you First Last Phone number of pastor or deaconHave you been baptized? Yes No How often do you read your Bible Never Occasionally Daily Problem Check ListSelect all that applyProblems Set 1 Anger Anxiety Apathy Appetite Bitterness Change in lifestyle Children Communication Conflict (fights) Deception Decision Making Problems Set 2 Depression Drunkeness Envy Fear Finances Gluttony Guilt Health Homosexuality Impotence In-laws Problems Set 3 Loneliness Lust Memory Moodiness Perfectionism Rebellion Sex Sleep Spouse Abuse A Vice Other List any other problems you are experiencing Add RemoveYou can add additional problems or issues by selecting the (+) button at the end of each row.Briefly answer the following questionsWhat is the problem or concern that brings you to counseling:What are your expectations from counseling:What have you done about this problem:Is there any other information we should know about:Personal InventoryRate yourself on each of the following traits. HonestNeverSeldomSometimesOftenUsuallyCourteousNeverSeldomSometimesOftenUsuallyCreativeNeverSeldomSometimesOftenUsuallySensitiveNeverSeldomSometimesOftenUsuallyGood father/motherNeverSeldomSometimesOftenUsuallyDecisiveNeverSeldomSometimesOftenUsuallyWork HardNeverSeldomSometimesOftenUsuallyEfficientNeverSeldomSometimesOftenUsuallyHumbleNeverSeldomSometimesOftenUsuallyForgivingNeverSeldomSometimesOftenUsuallyKeep my wordNeverSeldomSometimesOftenUsuallyGenerousNeverSeldomSometimesOftenUsuallyDependableNeverSeldomSometimesOftenUsuallyFrugalNeverSeldomSometimesOftenUsuallyTake advantage of othersNeverSeldomSometimesOftenUsuallyAppreciativeNeverSeldomSometimesOftenUsuallyUse peopleNeverSeldomSometimesOftenUsuallyHospitableNeverSeldomSometimesOftenUsuallyDiligentNeverSeldomSometimesOftenUsuallhyOptimisticNeverSeldomSometimesOftenUsuallyPlan aheadNeverSeldomSometimesOftenUsuallyDiscerningNeverSeldomSometimesOftenUsuallyKnow where you are goingNeverSeldomSometimesOftenUsuallyEncouragingNeverSeldomSometimesOftenUsuallyEnthusiasticNeverSeldomSometimesOftenUsuallyFairNeverSeldomSometimesOftenUsuallyConsistentNeverSeldomSometimesOftenUsuallyCourageousNeverSeldomSometimesOftenUsuallyProtectsNeverSeldomSometimesOftenUsuallyDiligentNeverSeldomSometimesOftenUsuallyAdmit when wrongNeverSeldomSometimesOftenUsuallyPatientNeverSeldomSometimesOftenUsuallyTeachableNeverSeldomSometimesOftenUsuallyConsiderateNeverSeldomSometimesOftenUsuallyAnalyticalNeverSeldomSometimesOftenUsuallyPersistentNeverSeldomSometimesOftenUsuallyPunctualNeverSeldomSometimesOftenUsuallyCooperativeNeverSeldomSometimesOftenUsuallyDisciplinedNeverSeldomSometimesOftenUsuallyNeatNeverSeldomSometimesOftenUsuallyCompassionateNeverSeldomSometimesOftenUsuallyResourcefulNeverSeldomSometimesOftenUsuallyObjectiveNeverSeldomSometimesOftenUsuallySincereNeverSeldomSometimesOftenUsuallyLovingNeverSeldomSometimesOftenUsuallyOtherAre there any other attributes you would like to comment on?Spiritual Convictions QuestionnaireDescribe Who God is:Describe who Jesus Christ is:Describe the kind of relationship you have with God and His Son Jesus Christ:What is the Definition of a Christian:I am or (I am not) a Christian because:What do you believe about the Bible:What is your definition of sin:What sins do you struggle with the most:How do you handle sin in your life:How do you handle guilt:What do you seek to accomplish in life:What do you tend to pray about the most:I do attend or I do not attend church because:I allow Christians or I do not allow Christians to be involved in my life because:What have you learned about yourself and what have you learned about your spouse (if married) and what changes do you need to make in light of this knowledge:CAPTCHANameThis field is for validation purposes and should be left unchanged. 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