Identification
Data:
Name:
Street Address:
City:
State:
Zip :
Email Address:
Country
Height
Age
Sex
Phone
Marital Status
(single, married, separated, divorced, widowed, going steady)
Education (last year completed)
Other training (list type and years)
Referred here by:
Address:
City: State:
Zip:
Phone:
Health Information:
Rate your health:
(very good, good, average, declining, other)
Your approximate weight:
List all important present or past illnesses, injuries or handicaps:
Date of last medical examination:
Report of that
examination:
Your physician:
Address:
City: State:
Zip:
Phone:
Are you presently taking medication?
(yes or no)
If so, what?
Have you used drugs for other than medical purposes?
(yes or no)
If so, name the drugs:
Have you ever had a severe emotional upset?
(yes or no)
If so, explain:
Have you ever been arrested? (yes
or no)
Are you willing to sign a release of information form so that your counselor
may
write for social, psychiatric, or medical reports?
(yes or no)
Religious Background:
Denominational preference:
Member:
Church attendance per month: (1x,
2x, 3x, 4x, 5x, 6x, 7x, 8x, 9x, 10+)
Church attended in childhood:
Baptized? (yes or no)
Religious background of spouse (if married):
Do you consider yourself a religious person?
(yes, no or uncertain)
Do you believe in God? (yes, no or
uncertain)
Are you saved? (yes, no or not sure
what you mean)
How much do you read the Bible?
(never, occasionally, often)
Do you have regular family devotions?
(yes or no)
Explain recent changes in your religious life, if any:
Personal Information:
Have you ever had any psychotherapy or counseling?
(yes or no)
If yes, list counselor or therapist and dates:
What
was the outcome?
Type in the box any of these words that 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, quiet, hard-boiled, submissive,
self-conscious,
lonely, sensitive, other:
Have you ever felt like people were watching you?
(yes or no)
Do people's faces ever seem distorted?
(yes or no)
Do you ever have difficulty distinguishing faces?
(yes or no)
Do colors ever seem too bright?
(yes or no)
Are you sometimes unable to judge distance?
(yes or no)
Have you ever had hallucinations?
(yes or no)
Are you afraid of being in a car?
(yes or no)
Is your hearing exceptionally good?
(yes or no)
Do you have problems sleeping? (yes
or no)
Marriage
& Family Information:
Name of spouse:
Address:
City:
State:
Zip:
Phone:
Occupation:
Your
spouse's age: Education (in years)
Religion:
Is your
spouse willing to come for counseling?
(yes or no)
Have
you ever been separated? (yes or
no)
Has
either of you ever filed for divorce?
(yes or no)
If so,
when?
Date of
marriage:
Your
ages when married: Husband's age
Wife's age
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:
Living?
(yes or no)
Education in
years:
Marital
status:
Name: Age:
Living?
(yes or no)
Education in
years:
Marital
status:
Name:
Age:
Living?
(yes or no)
Education in
years:
Marital
status:
Name: Age:
Living?
(yes or no)
Education in
years:
Marital
status:
If you were
reared by anyone other than your own parents, briefly explain:
How many
older siblings do you have?
How many
brothers?
How many
sisters?
Thank you for
filling out this information.
