PERSONAL DATA INVENTORY

Instructions: This is a Personal Data Inventory and is required before we will agree to counsel anyone at Fellowship Biblical Counseling. All fields are required. If something is not applicable, then type N/A. All answers are kept strictly confidential, unless the counselor deems it necessary to contact authorities for crimes or misconduct. The counselor reserves the right to seek advice from other counselors in all matters.

IDENTIFICATION DATA
Name *
Name
Address
Address
Marital Status *
HEALTH INFORMATION
Rate Your Physical Health *
Date of Last Examination *
Date of Last Examination
Are you willing to sign a release of information form so that your counselor may write for helpful social, psychiatric, or medical report? *
Have you ever used drugs for anything other than medical purposes? *
Are you currently taking any medication?
Prescribed? *
RELIGIOUS BACKGROUND
Are you the member of a church? *
Church attendance per month *
Have you been baptized? *
Are you saved? *
MARRIAGE INFORMATION
*If you've never been married, please skip down to the section on children. If you do not have children please enter, N/A.
Address 1
Address 1
Phone
Phone