Personal Data Inventory

Identification Data:                                                                       Date:_____________________

Name __________________________________                        Home Phone (____)____________

Address ______________________________ City ___________________ State ____ Zip _______

Occupation _______________________________________ Business Phone (___) _____________

Sex _________  Birth Date ____________  Age _________  Height _________

Marital Status:  Single __  Going Steady __  Married __  Separated __  Divorced __ Widowed __

Education (last year completed): _______ (grade) ______ Other training (list type and years  _____

__________________________________________________________________________________

Referred here by ________________________  Address ___________________________________

City __________________________ State _______ Zip ________ Phone (____) ________________

Health Information:

Rate you health (check): Very Good ___  Good ___  Average ___  Declining ___  Other ____

Your approximate weight ________lbs.  Weight changes recently:  Lost _______  Gained ______

List all important present or past illnesses, injuries or handicaps: ____________________________

__________________________________________________________________________________

Date of last medical examination ______________________  Report: _________________________

__________________________________________________________________________________

Your physician _______________________________  Address ______________________________

City __________________________ State _______ Zip ________ Phone (____) ________________

Are you presently taking medication? Yes ____  No _____  What? ___________________________

Have you used drugs for other than medical purposes?  Yes ____  No ____  What? _____________

Have you ever had a severe emotional upset?  Yes ____  No ____  Explain: ___________________

__________________________________________________________________________________

Have you ever been arrested?  Yes ____  No ____

Are you willing to sign a release of information form so that your counselor may write for social, psychiatric,

or medical reports?  Yes ____  No ____

Religious Background:

Denominational preference: _____________________  Member: ______________________________

Church attendance per month (circle): 0   1   2   3   4   5   6   7   8   9   10+

Church attended in childhood: ___________________________________ Baptized?  Yes ____  No ____

Religious background of spouse (if married) _________________________________________________

Do you consider yourself a religious person? Yes ____  No ____  Uncertain ____

Do you believe in God?  Yes ____  No ____  Uncertain ____

Are you saved?  Yes ____  No ____  Not sure what you mean ____

How much do you read the Bible?  Never ____  Occasionally ____  Often ____

Do you have regular family devotions? Yes ____  No ____

Explain recent changes in your religious life, if any ____________________________________________

______________________________________________________________________________________

Personality Information:

Have you ever had any psychotherapy or counseling before?  Yes ____  No ____

If yes, list counselor or therapist and dates: ________________________________________________

____________________________________________________________________________________

What was the outcome? _______________________________________________________________

Circle any of the following words which best describe you now:

active   ambitious  self-confident  persistent  nervous  hardworking  impatient  impulsive  moody  often-blue

excitable  imaginative  calm  serious  easy-going  shy  good-natured  introvert  extrovert  likable  leader  quite

hard-boiled  submissive 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 a car?  Yes ____  No ____

Is your hearing exceptionally good?  Yes ____  No ____

Do you have problems sleeping?  Yes ____  No ____

Marriage and Family Information:

Name of spouse ___________________________________ Address _________________________________

City ______________________________________ State ____  Zip ________ Phone (____) _______________

Occupation _______________________________________________ Business Phone (____) _____________

You spouse's age _____ Education (in years) ________________________ Religion ____________________

Is your spouse willing to come for counseling?  Yes ____  No ____

Have you ever been separated?  Yes ____  No ____  When? from __________  to ___________

Has either of you ever filed for divorce?  Yes ____  No ____  When? _________________________

Date of marriage ________________________ Your ages when married: Husband ________  Wife __________

How long did you know your spouse before marriage?_______________________________________________

Length of steady dating with spouse ______________________ Length of engagement ___________________

Give brief information about any previous marriages: ________________________________________________

___________________________________________________________________________________________

Information about children:

       Name                                                              Age    Sex     Living?    Education          Marital

                                                                                                  Yes/No    (in years)            Status 

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

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* Check this column if child is by previous marriage

If you were reared by anyone other than your own parents, briefly explain: _______________________________

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How many older siblings do you have?      brothers _______  sisters _______

How many younger siblings do you have?  brothers _______  sisters _______          

Please Mail this Form to:
New Beginnings House of Prayer
P.O. Box 214
Leavenworth, KS 66048