CONFIDENTIAL PERSONAL DATA INVENTORY · Web viewMe Equally Spouse How hopeful are you about...

CONFIDENTIAL PERSONAL DATA INVENTORY

By completing this questionnaire as fully and accurately as possible, you will facilitate your therapeutic process. If married, you and your spouse are each asked to fill out separate forms. It is understandable that you might be concerned about what happens to the information about you because much of or all of this information is highly personal. Case records are strictly confidential. No outsider is permitted to see your case record without your permission.

PERSONAL INFORMATION Date ______________

Name________________________________ Birth Date: _______________ Age _______

Address: _________________________________City ___________State ____Zip __________

Telephone: Home: _______________________ Work: ________________________

Mobile: _______________________ May we leave you a message? Yes No

E-mail: _________________________________________ May we email you? Yes No How did you hear about Broken Chains International? Family/Friend Internet (website name) _________________________ Minister/Clergy Ministry/Professional Organization (name) Physician Other Professional (name) Former Client Seminar (please specify) Other (please specify) ___________________________

If you were referred by a professional, may we contact them to express our appreciation? Yes No

If yes, please provide name, telephone number and other contact information (if known __________________________

_____________________________________________________________________

Marital Status: Single Engaged Married Separated Divorced Widowed Remarried ____ times

This is your #______marriage Hobbies: _____________________________________________________________

Gender (check): Male Female Learning Style (check): Auditory Visual Kinesthetic (multi-sensory)

Were you adopted? Yes No If yes, at what age: _________

Ethnicity (check): Caucasian African-American Hispanic Native American Asian Other ___________

1P.O. Box 801096, Acworth, GA 30101

: USA (800) 910-5060 Fax: (800) 634-6360 International +1.678.608.2111: [email protected] : www.BrokenChainsIntl.com

http://www.brokenchainsintl.com/

mailto:[email protected]

Education: Please circle the number that most closely represents your level of education (years):

High School College Graduate School Other ____ 7 8 9 10 11 12 13 14 15 16 17 18 19 20 other _____

Please specify the highest educational degree attained: _____________________________________

Employment

What is your current occupation? _________________________________Years__________

Name of Employer? _________________________________Years employed__________

If retired, what was your occupation? ____________________________ Years ___________

Is scholarship funding requested? Yes No Scholarship funding is available upon request, please ask your counselor or client care specialist for our Scholarship Application at your session.

Please check your total household income: ____ less than $20,000____ 20,000 to 30,000____ 30,000 to 40,000____ 40,000 to 60,000____ 60,000 to 80,000____ more than $80,000 per year

HEALTH

Describe your health ____________________________________________________________

Do you have any chronic conditions? _______ If so what? ______________________________

Does your spouse have any chronic health conditions or disabilities? yes / no Please list condition(s): ____________________________________________________

Do any of your children have chronic health conditions or disabilities? yes / no Please list condition(s):_____________________________________________________

List important illnesses and injuries or handicaps ______________________________________





Date of last medical exam _____________ Report _____________________________________

Your height____________ Weight_________ Spouse's height_______ Weight__________

Do you consider yourself overweight? _________

Does your spouse consider herself/himself overweight? _______

How much physical exercise do you average per week? ________________

Do you consider yourself physically fit? _____________

Does your spouse consider herself/himself physically fit? ______________ Are you presently under the care of a medical practitioner? ________________

If yes, for what condition: _____________________________________For how long: _______

Current Medication(s) and dosage and length of use? ___________________________________

______________________________________________________________________________

Have you ever used drugs for other than medical purposes ______If yes, please explain _______

______________________________________________________________________________

Do you drink beer / alcohol? yes / no Amount/frequency __________________________ Has your spouse ever indicated that your drinking is a problem? yes / no

Have you ever used “drugs”? yes / no If yes, what type? _____________________________ When? _______________________

Does your spouse drink alcohol? yes / no Amount/frequency ____________________ Have you ever felt your spouse’s drinking is a problem? yes / no

Has your spouse ever used “drugs”? yes / no If yes, what type? __________________________ When? _______________________





In your estimation, did one or both of your parents have a drinking or drug problem during your childhood? yes / no

_______________________________________________________________________

Do you drink coffee _____ How much ______________________________________________

Other caffeine drinks _____ How much _____________________________________________

Do you smoke _______ What ____________________ Frequency ________________________

Have you at any time been under the care of another Christian counselor, pastor, etc? Y__ / N__

If yes, who, when, and for what problem: ______________________________________

______________________________________________________________________________

Have you at any time been under the care of any mental health professional? Y__ / N__

If yes, who, when, and for what problem: ______________________________________

______________________________________________________________________________

Are you aware of any physical problems that impair your functioning? _____ If yes, what

problem(s): ____________________________________________________________________

SPIRITUAL

Denominational Preference: ____________ Church attending ____________________________

Circle the number of church-related/religion-related functions you attend per month: Less than 1 1-2 3-4 5-6 7-8 9-10 More than 10

All things considered, how central is your faith / religion in your daily life?

1 2 3 4 5 6 7not at all somewhat veryimportant important important





Explain any recent changes in your religious life ______________________________________

______________________________________________________________________________

WOMEN ONLY

Have you had any menstrual difficulties_______ Do you experience tension, tendency to cry,

or other symptoms prior to your cycle; please explain __________________________________

______________________________________________________________________________

Is your husband willing to come for counseling _______________________________________

Is he in favor of you coming ________________ If no, please explain _____________________

______________________________________________________________________________

FOR MEN AND WOMEN Circle any of the following words which best describe you now: active ambitious self-confident persistent nervous hardworking impatient impulsive moody kindly often-blue excitable imaginative calm serious easy-going shy good-natured introvert extrovert likeable leader quiet hard-boiled submissive spiritual self-conscious lonely sensitive other

Have you ever felt people were watching you? Yes ________ No__________

Do people’s faces ever seem distorted? Yes ________ No__________

Do you ever have difficulty distinguishing faces? Yes ________ No__________

Do colors ever seem too bright? Yes ________ No__________

Are you sometimes unable to judge distance? Yes ________ No__________

Have you ever had hallucinations? Yes ________ No__________

Are you afraid of being in the car? Yes ________ No__________

Is your hearing exceptionally good? Yes ________ No__________5

P.O. Box 801096, Acworth, GA 30101 : USA (800) 910-5060 Fax: (800) 634-6360 International +1.678.608.2111

: [email protected] : www.BrokenChainsIntl.com



Do you have problems sleeping? Yes ________ No__________

PROBLEM CHECKLIST

NERVOUSNESS SHYNESS SUICIDAL THOUGHTS DEPRESSION SEPARATION

DRUG USE ANGER SLEEP RELAXATION LEGAL MATTERS ENERGY LONELINESS EDUCATION TEMPER CHILDRENBOWEL TROUBLES SMOKING RELATIONSHIPS SEXUAL PROBLEMS DIVORCE ALCOHOL USE SELF-CONTROL STRESS HEADACHES MEMORY INSOMNIA INFERIORITY CAREER CHOICES NIGHTMARES APPETITEBEING A PARENT WEIGHT FEARS FINANCES FRIENDS UNHAPPINESS WORK TIREDNESS AMBITION MAKING DECISIONS CONCENTRATION HEALTH MARRIAGE STOMACH TROUBLING THOUGHTSPAIN OTHER PHYSICAL OTHER EMOTIONAL

In your estimation, who was more interested in coming to counseling?

1 2 3 4 5 6 7 Mainly Both Mainly Me Equally Spouse

How hopeful are you about achieving a satisfying marriage?

1 2 3 4 5 Extremely Not hopeful Indifferent Hopeful Extremely

hopeless or neutral hopeful

How much time do you and your spouse talk during an average week?

less than 30 minutes 1-2 hours 6 - 10 hours_ 30 mins. to an hour 3-5 hours more than 10

Were you ever a victim of physical abuse? yes / no If yes, how old were you? _______

Were you ever a victim of sexual abuse? yes / no If yes, how old were you? _______

Were you ever a victim of verbal abuse? yes / no If yes, how old were you? _______





Were you ever a victim of neglect? yes / no If yes, how old were you? _______

What are the problems that led you to decide to come to counseling/coaching?

______________________________________________________________________________

______________________________________________________________________________

MARRIAGE AND FAMILY

Spouse: ___________________________________ Birth Date: ________________Age: _____

Occupation: _______________________________Years Employed ______________________

Telephone: Home: _______________________ Work: ________________________

Cell/Mobile: _______________________ Page: _________________________

This is your spouse's #______marriage. Date of Marriage _____________ Length Dating _____

Hobbies: ______________________________________________________________________

Give a brief statement of circumstances of meeting and dating ___________________________

______________________________________________________________________________

Did you live together before marriage? yes / no If yes, how long? _______

Number of your children: __________ Names and Ages (please indicate if by previous marriage):

Name Age Sex Living Yr. Ed. Step-child1. ____________________________________________________________________________

2. ____________________________________________________________________________

3. ____________________________________________________________________________

4. ____________________________________________________________________________

5. ____________________________________________________________________________

6. ____________________________________________________________________________7





In regards to your living situation, are you currently living (X which applies)___ Together: in same home, same room___ Together: Same home, separate rooms___ Separated, not pursuing divorce___ Separated, pursuing divorce

How committed are you to your marriage at this time?

1 2 3 4 5 Pursuing Weakening Neutral Solid Divorce isn’t an optionSeparation/divorce for you as an individual

Your siblings, beginning from oldest to youngest --- include yourself: Living Living

1. _____________________ Age ( ) _____ 6. ____________________ Age ( ) _____

2. _____________________ Age ( ) _____ 7. ____________________ Age ( ) _____

3. _____________________ Age ( ) _____ 8. ____________________ Age ( ) _____

4. _____________________ Age ( ) _____ 9. ____________________ Age ( ) _____

5. _____________________ Age ( ) _____ 10. ___________________ Age ( ) _____

In your estimation, how happy was/is your parent’s marriage?

1 2 3 4 5 6 7 not at all somewhat very happy happy happy

Did your parents get divorced? yes / no If yes, how old were you? ______

Were you raised in a blended family (with step-parents or step-siblings)? yes / no

Are your parents living? ________ Do they live locally? _______________________________

Did you live with anyone other than your parents? ______ If so, whom ____________________

______________________________________________________________________________

I attest that the above information is true and correct 8





Signature: ___________________________________ Date: ________________





CONFIDENTIAL PERSONAL DATA INVENTORY · Web viewMe Equally Spouse How hopeful are you about...

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