161 East Harper Avenue, Maryville, TN  865-984-0116

Personal Data Inventory

The Biblical Counseling Ministry
Personal Data Inventory

Please complete this inventory carefully

Personal Identification
Name: _____________________________________ Birth Date: ________________ Phone: ________________________
Email:______________________ Age:___________ Sex:______________ Referred By:_____________________________
Address:________________________________________________________________ Zip Code:___________________
Marital Status:  Single      ◊Engaged        ◊Married         Separated        Divorced          Widowed
Education (last year completed):__________________________________________________________________________
Employer:__________________________________ Position:_________________________________________________
Years:__________________ Work Phone:_____________________________Weekly Work/School Hours:________________

Marriage and Family
Spouse:_______________________________________________ Birth Date:_________________________ Age:________
Occupation:_________________________________ How Long Employed:____________________
Home Phone:_________________________________ Work Phone:_____________________________
Date of Marriage:_________________________________ Length of Dating: ______________________________
Give a brief statement of circumstances of meeting and dating: ______________________________________________________
_________________________________________________________________________________________________
Have either of you been previously married:_________________ To Whom:_________________________
Have you ever been separated:________________________ Filed for divorce:________________________

Information about Children:
First Name:___________________ Age:____ Sex:___ Living: _____ Year Ed.: ______ Step-Child:___
Second Name:_________________ Age:____ Sex:___ Living: _____ Year Ed.: ______ Step-Child:___
Third Name:__________________ Age: ____ Sex:___ Living: _____ Year Ed.: ______ Step-Child: ___
Fourth Name:_________________ Age: ____ Sex:___ Living: _____ Year Ed.: ______ Step-Child: ___
Fifth Name: __________________ Age: ____ Sex:___ Living: _____ Year Ed.: ______ Step-Child: ___
Sixth Name: __________________ Age: ____ Sex:___ Living: _____ Year Ed.: ______ Step-Child: ___

Parents still married:______________________ Parents living:________________ Parents live locally:___________________
Parent’s religious convictions, were/are they believers:__________________________________________________________ _______________________________________________________________________________________________
Describe relationship to your father: ______________________________________________________________________
_______________________________________________________________________________________________
Describe relationship to your mother:_____________________________________________________________________
_______________________________________________________________________________________________
Number of sibling(s):____________ Your sibling order:_______________________________________________________
Do you or did you live with anyone other than parents:__________________________________________________________

Health
Describe your overall health:___________________________________________________________________________
Do you have any chronic conditions, important illnesses, injuries and/or handicaps: _____________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Date of last medical exam:_____________ Report:__________________________________________________________
Do you have a family doctor or physician you see regularly:_______________________________________________________
Current medication(s) and dosage:_______________________________________________________________________
_______________________________________________________________________________________________
Have you ever-used drugs for anything other than medical purposes:________________________________ If yes, please explain:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Have you ever been arrested: _____________________Do you drink alcoholic beverages: _______
If so, how often & how much:_______________________ Do you drink coffee:____________ How much:_________________
Other caffeine drinks: ________ How much: __________
Use tobacco: ________ What: ___________ Frequency: ___________
Describe your normal sleeping schedule: ___________________________________________________________________
Have you ever had interpersonal problems on the job? If so, please describe: ___________________________________________
_______________________________________________________________________________________________
Have you ever had a severe emotional upset:_________ If yes, please explain:_________________________________________
________________________________________________________________________________________________
Have you ever seen a psychiatrist or counselor:____________ If yes, please explain: ____________________________________
________________________________________________________________________________________________
Are you willing to sign a release of information form so that your counselor may write for social, psychiatric, or other medical records: _____

Spiritual
Denominational preference:_________________________ Church attending: _______________________________________
Member:_________________ Pastor’s Name:__________________________ Pastor’s Phone Number: ___________________
Church attendance per month:____________ Do you believe in God:________________ Do you pray: ______________________
Would you say that you are a Christian:____________ , OR still in the process of becoming a Christian:________________________
Have you ever been baptized:________________________
How often do you read the Bible:_________________ Are you involved in ministry: ____________________________________
Have you ever been discipled? If yes, please describe:____________________________________________________________
________________________________________________________________________________________________
Explain any recent changes in your religious life:_______________________________________________________________
________________________________________________________________________________________________
What are the three biggest positive influences on your spiritual life:__________________________________________________
________________________________________________________________________________________________
What are the three biggest negative influences on your spiritual life: _________________________________________________
________________________________________________________________________________________________
Have you shared the problems for which you are seeking counseling with your pastor and/or other mature members of your church? If yes,
please write down their names. If no, please describe any concerns you have about doing so:_________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

Women Only
Have you had any menstrual difficulties: ______________ If you experience tension, tendency to cry, other symptoms prior to your cycle,
please explain:______________________________________________________________________________________
Is your husband willing to come for counseling: ___________________ Is he in favor of your coming:_______________
If no, please explain:__________________________________________________________________________________
________________________________________________________________________________________________

Problem Severity: Please rate how these items impact your life
(blank) = no significant impact; 1= mild impact; 2 = moderate impact; 3 = severe impact

_____ Anger                                                 _____Discouraged/Downcast                                           _____Memory
_____Anxiety                                              _____Drunkenness                                                              _____Moodiness
_____ Apathy                                               _____Envy                                                                             _____Overwhelmed
_____Appetite                                             _____Fear                                                                              _____Perfectionism
_____Bitterness                                          _____Finances                                                                      _____Pornography
_____Change in lifestyle                           _____Gluttony                                                                      _____Procrastination
_____Children                                             _____Guilt                                                                             _____Rebellion
_____Communication                               _____Health                                                                          _____Sexual Immorality
_____Conflict (fights)                               _____Homosexuality                                                            _____Sex (in marriage)
_____Control                                              _____Impotence                                                                   _____Sleep
_____Deception                                         _____In-laws                                                                         _____Spouse Abuse
_____Decision Making                             _____Laziness                                                                       _____Time Usage
_____Depression                                       _____Loneliness                                                                   _____Weary
_____Disciplined Living                          _____Lust                                                                               _____Other
_____Disorganization                              _____Marriage

Briefly Answer the Following Questions

1. Why have you sought counseling? What difficulties are you facing?

2. What have you done about the difficulties?

3. What are your expectations from counseling?

4. Is there any other information that we should know?