* This form was taken from The Pastor & Counseling by Jeremy Pierre and Deepak Reju, which was developed in part from the Personal Data Inventory in Jay E. Adams, Competent to Counsel: Introduction to Nouthetic Counseling (Grand Rapids: Zondervan, 1970), as well as unpublished training material from Stuart Scott.]
MARRIAGE & FAMILY
Few relationships are as involved in your daily experience as family. We’ll need the basics to understand how best to help you. If there is anything you think we should know that isn’t mentioned in this section, please feel free to write it in.
Please list their name, age, sex, education, and if they are stepchildren.
GROWING UP YEARS
While we don’t think that childhood experiences strictly determine how we respond as adults, we do recognize that past experience influences present perspectives. So we will ask you to describe the family you came from. Again, if there is anything you think we should know that isn’t mentioned in this section, please feel free to write it in.
We are physical as well as spiritual beings, and our bodies are important factors in our experience. Though we counselors are not medical professionals, it’s helpful for us to know general facts about your health.
Physician's name and address:
While we view all of human life as spiritual in nature, our religious identification indicates a lot about how we exercise our spirituality. We ask this information to get a better grasp of how you pursue God in your life experience.
Please note any significant changes in your religious life.