Soul Care Ministry Personal Data Inventory*All information provided on this form will be kept confidential in the same manner as that disclosed during counseling sessions. Name * First Name Last Name Cell Phone * (###) ### #### Home Phone (###) ### #### Email Address * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Birth * MM DD YYYY Place of Employment Work Phone (###) ### #### Marital Status * Single Married Separated Widowed Divorced Education (last year completed) Degree or Certificates Other Training Referred By Health Information Rate your Health Select One Very Good Good Average Declining Poor Weight change recently Lost/Gained (Number of pounds) List all present and (or) past illnesses, injuries, or handicaps: Date of last medical examination MM DD YYYY Report Physician's name and address Are you presently taking medication? Select One Yes No If yes, list: Have you had recent fevers or elevated temperatures? Select One Yes No Does your heart ever race or beat irregularly? Do you know your blood pressure? Is it normal? Have you ever been arrested? Select One Yes No If yes, when? MM DD YYYY State the circumstances Religious Background Denominational Preference * Membership Church Attendance per Month * Select One 0 1 2 3 4 5 6 7 8 9 10+ Church attended in childhood Religious background of spouse (if married) Do you believe in God? * Select One Yes No Uncertain Do you pray to God? * Select One Often Occasionally Never Are you saved? * Select One Yes No Not sure what you mean Have you been baptized? * Select One Yes No If yes, at what age? How frequently do you read the Bible? * Select One Often Occasionally Never Do you have regular family devotions? * Select One Yes No Marriage and Family information Name of Spouse Address (if different) Phone (###) ### #### Occupation Work Phone (###) ### #### Spouse's Age Education In years Religion Is your spouse willing to come to counseling? Select One Yes No Uncertain N/A Have you ever been separated? Select One Yes No N/A If yes, when? Has either of you ever filed for divorce? Select One Yes No N/A If yes, when? Date of Marriage MM DD YYYY 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? * Select One Yes No Who and When Personality Information Have you ever used drugs for reasons other than medical purposes? * Select One Yes No What When Have you ever had a severe emotional upset? * Select One Yes No If yes, explain Have you ever had any psychotherapy or counseling before? * Select One Yes No If yes, list dates What was the outcome? Check any of the following 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 Likeable Leader Quiet Hard-boiled Submissive Self-conscious Lonely Sensitive Have you ever had any hallucinations? * Select One Yes No Do you have problems sleeping? * Select One Yes No How many hours of sleep do you average each night? * Pastoral information Pastor's Name Phone (###) ### #### Church Name Phone (###) ### #### Church Address Address 1 Address 2 City State/Province Zip/Postal Code Country Permission to consult with pastor as deemed helpful by counselor * Select One Yes No 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? Thank you! Our Soul Care ministry will be reaching out to you shortly. If you are not contacted within two weeks, please email grow@lifeatcrossroads.org.
