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GriefShare
Ministries
Sermons
Visit
About
Contact
Make a Donation
Counseling
Counseling
Counseling Resources
Links
Personal Data Inventory
Redeemer Counseling Ministries
Identification Data
Date
*
Enter today's date
Name
*
First Name
Last Name
Address
*
City
*
State
*
Zip Code
*
Second Address (optional)
Second City (optional)
Second State (optional)
Second Zip Code (optional)
Occupation
*
Email Address
*
Mobile Phone
*
Home Phone (optional)
Business Phone (optional)
Sex
*
Age
*
Date of Birth
*
Approximate Height
*
Marital Status
*
Select
Single
Going Steady
Married
Separated
Divorced
Widowed
Education
*
Select Highest Level
Select
Below High school
High school
GED
Currently in college
Associate degree
Bachelor's degree
Master's degree
Doctoral degree
Have you ever been arrested?
*
Select
Yes
No
Who were you referred by? (optional)
Health Information
Rate your health
*
Select
Very good
Good
Average
Below average
Declining
Approximate Weight
*
Weight changes recently (If none, type none)
*
Noticeable loss or gain in weight recently
List all important present or past illnesses, injuries or handicaps (If none, type none)
*
Date of last medical examination
*
Report
*
Your physician
*
Physician's Address
*
Physician's City
*
Physician's State
*
Physician's Zip Code
*
Physician's Phone Number
*
Briefly describe any medication you may be currently taking (If none, type none)
*
Briefly describe any drugs you have used for non-medical purposes (If none, type none)
*
Briefly describe any severe emotional upsets you have had (If none, type none)
*
Are you willing to sign a release of information form so that your counselor may write for social, psychiatric, or medical reports?
*
Select
Yes
No
Religious Background
Denomination Preference (If none, type none)
*
Are you a member of a church?
*
Select
Yes
No
If you are attending a church, please provide what church you are attending and the pastor's name
May I call him?
Select
Yes
No
Not Applicable
If so, please provide a number in which we can contact your pastor (Church's number and/or their phone number)
How many times to you attend church per month?
Select
Not Applicable
1
2
3
4
5
6
7
8
9
10+
Are you involved in ministry?
Select
Yes
No
Not applicable
Briefly describe the religious background of your spouse (If married)
Do you consider yourself a religious person?
*
Select
Yes
No
Uncertain
Do you believe in God?
*
Select
Yes
No
Uncertain
Do you pray to God?
*
Select
Never
Occasionally
Often
Are you saved?
*
Select
Yes
No
Not sure what you mean
How often do you read the Bible?
*
Select
Not Applicable
Never
Occasionally
Often
Do you have regular family devotions?
*
Select
Yes
No
Not Applicable
Explain recent changes in your religious life (If any)
Personality Information
If you have ever had any psychotherapy or counseling before, please list the counselor or therapist and dates, as well as what the outcome was
Select any of the following words which best describes you now:
*
Active
Ambitious
Self-confident
Persistent
Nervous
Hardworking
Impatient
Impulsive
Moody
Often-blue
Excitable
Calm
Serious
Easy-going
Shy
Good-natured
Introvert
Extrovert
Likable
Leader
Quiet
Hard-boiled
Submissive
Self-conscious
Lonely
Sensitive
Other
If other, what other words do you think describe you?
Have you ever felt people were watching you?
*
Select
Yes
No
Do people's faces ever seen distorted?
*
Select
Yes
No
Do you ever have difficulty distinguishing faces?
*
Select
Yes
No
Do colors ever seem too bright?
*
Select
Yes
No
Do colors ever seem too dull?
*
Select
Yes
No
Are you sometimes unable to judge distance?
*
Select
Yes
No
Have you ever had hallucinations?
*
Select
Yes
No
Are you afraid of being in a car?
*
Select
Yes
No
Is your hearing exceptionally good?
*
Select
Yes
No
Do you have problems sleeping?
*
Select
Yes
No
Marriage and Family Information, Please skip any non-applicable questions
Name of spouse
Their Address
City
State
Zip Code
Phone number
Occupation
Business Phone
Spouse's age
Their Education
Select Highest Level
Select
Below High school
High school
GED
Currently in college
Associate degree
Bachelor's degree
Master's degree
Doctoral degree
Their Religion
Is your spouse willing to come for counseling?
Select
Yes
No
Uncertain
If you have ever been separated, Please provide dates and brief descriptions if applicable
If you have ever filed for divorce please provide when
Date of marriage
Husband's age when married
Wife's age when married
How long did you know your spouse before marriage?
Length of steady dating before marriage?
Length of engagement
Give brief information about any previous marriage
Please give some information about your children
Please tell us their Name, Age, Sex, If they are living (Yes/No), Education, Martial Status and if they are from a previous marriage.
If you were raised by anyone other than your own parents, briefly explain.
How many older siblings do you have?
How many younger siblings do you have?
Briefly answer the following questions
What is the main problem, as you see it? What brings you here?
What have you done about it?
What can we do? What are your expectations in coming here?
As you see yourself, what kind of person are you? Describe yourself.
Is there any other information we should know?
Thank you! We will get back to you shorty.
