Email Address

Place of Employment

Education (last year completed)

Degree or Certificates

Other Training

Referred By

Health Information

Rate your Health

Weight change recently

Lost/Gained (Number of pounds)

List all present and (or) past illnesses, injuries, or handicaps:

Report

Physician's name and address

Are you presently taking medication?

If yes, list:

Have you had recent fevers or elevated temperatures?

Does your heart ever race or beat irregularly?

Do you know your blood pressure? Is it normal?

Have you ever been arrested?

State the circumstances

Religious Background

Denominational Preference

Membership

Church Attendance per Month

Church attended in childhood

Religious background of spouse (if married)

Do you believe in God?

Do you pray to God?

Are you saved?

Have you been baptized?

If yes, at what age?

How frequently do you read the Bible?

Do you have regular family devotions?

Marriage and Family information

Name of Spouse

Address (if different)

Occupation

Spouse's Age

Education

In years

Religion

Is your spouse willing to come to counseling?

Have you ever been separated?

If yes, when?

Has either of you ever filed for divorce?

If yes, when?

Husband's age when married

Wife's age when married

How long did you know your spouse before marriage?

Length of Dating

Length of Engagement

Give brief information about any previous marriages

Information about Children

Please list: Name, Age, Sex, Living (Yes/No), Education, Marital Status

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

How many older brothers and/or sisters do you have?

How many younger brothers and/or sisters do you have?

Have there been any deaths in the family in the last year?

Who and When

Personality Information

Have you ever used drugs for reasons other than medical purposes?

What

When

Have you ever had a severe emotional upset?

If yes, explain

Have you ever had any psychotherapy or counseling before?

If yes, list dates

What was the outcome?

Have you ever had any hallucinations?

Do you have problems sleeping?

How many hours of sleep do you average each night?

Pastoral information

Pastor's Name

Church Name

Permission to consult with pastor as deemed helpful by counselor

Briefly Answer the Following Questions

What brings you here?

What have you done about it?

What are your expectations in coming here?

Is there any other information we should know?

Soul Care Ministry Personal Data Inventory

In Person and Online Weekend Worship Services