Name *
* 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in Jay E. Adams, Competent to Counsel: Introduction to Nouthetic Counseling (Grand Rapids: Zondervan, 1970), as well as unpublished training material from Stuart Scott.]
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.
Date of Birth:
Date of Birth:
Date of Marriage:
Date of Marriage:
Have either of you been previously married?
Have either of you ever been separated from one another?
Have you ever filed for divorce?
Please list their name, age, sex, education, and if they are stepchildren.
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:
Date of last medical exam:
Date of last medical exam:
Have you ever seen a psychiatrist or psychologist?
Date of last appointment:
Date of last appointment:
Are you willing to sign a release form information form so that your counselor may attain social, psychiatric or other medical records?
Have you ever used drugs for anything other than medical purposes?
Substance Use
Alcoholic beverages?
Tobacco products?
Have you ever been arrested?
Have you ever had interpersonal problems on the job?
Have you had any recent trauma or any significant life changes?
Women Only
Children Only
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.
Are you a member?
Please note any significant changes in your religious life.
Which statement best describes your relationship to Jesus Christ? If you don’t like any of these, write your own.