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
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 ______________________________________
2P.O. Box 801096, Acworth, GA 30101
: USA (800) 910-5060 Fax: (800) 634-6360 International +1.678.608.2111: [email protected] : www.BrokenChainsIntl.com
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? _______________________
3P.O. Box 801096, Acworth, GA 30101
: USA (800) 910-5060 Fax: (800) 634-6360 International +1.678.608.2111: [email protected] : www.BrokenChainsIntl.com
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
4P.O. Box 801096, Acworth, GA 30101
: USA (800) 910-5060 Fax: (800) 634-6360 International +1.678.608.2111: [email protected] : www.BrokenChainsIntl.com
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? _______
6P.O. Box 801096, Acworth, GA 30101
: USA (800) 910-5060 Fax: (800) 634-6360 International +1.678.608.2111: [email protected] : www.BrokenChainsIntl.com
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
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
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
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
Signature: ___________________________________ Date: ________________
9P.O. Box 801096, Acworth, GA 30101
: USA (800) 910-5060 Fax: (800) 634-6360 International +1.678.608.2111: [email protected] : www.BrokenChainsIntl.com
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