Personal Data Inventory

This PDI is for new clients who have a scheduled appointment with one of our counselors. By filling out the information online you will be able to save some time that would otherwise be needed to fill out paperwork during your first appointment. When typing in the form below, please do NOT hit the enter key unless you are finished.



Last Year of School Completed:






College Education:




Employment Information:

Early Family History:

If you were reared by someone other than your biological parents, please explain:

In your childhood home, did you live with anyone who was:





Marital Information:








Education of Spouse:





Is your spouse willing to come for counseling?



Ages when married:

Please provide information about previous marriages:

Children:

Please list your children's names, ages, sex, and relationship to you (please note if children are from a previous marriage):

Are your children living at home?

Counseling History:

Have you ever been to counseling for any reason?



Have you ever had a severe emotion upset?



If yes, please explain

Are you presently working with any other counselor or psychologist?



Are you involved in any other marriage counseling, family counseling, or support groups?



If yes, please specify

Briefly state the problem as you see it:

What have you done to try to resolve these matters?

What do you want to gain from counseling?

Who referred you to this counseling office?

Is there any other information we should have?

Religious Background:

What church do you attend, if any?

What is your pastor's name and phone number?

How strong is the influence of your church in your life?




Religious/church background of your spouse:

Have you come to a place in your spiritual life where you can say that you know for certain that if you were to die today you would go to heaven?



Have you had any recent changes in your spiritual life?



If yes, please explain?

Select the following words which best describe your normal self (check all that apply)
















































List any fears that you have:

Medical Information:

Are you taking prescription drugs?



If yes, state the drug name(s)/purpose:

Describe your physical health:





Have you ever been hospitalized for mental illness or substance abuse?



If yes, for what reason?

How long were you in treatment?

Did you continue with outpatient counseling?



Drugs used other than for medical purposes:

When was the last time for use?

Any recent weight changes?

Have you had any of the following physical problems in the past 2 years? (check all that apply)


















List any surgeries, major illnesses or physical disabilities and dates:

Impact of Life Circumstances:

Check any LOSSES that you have experienced in the last two years:

Death of:










Other Losses:












If other, please specify:

Check any VICTIMIZATIONS you have experienced or been involved with:

Child Abuse:





Spouse Abuse:





Other:










If other, please specify:

Check any PROBLEMS that concern you now:


































If other, please specify:

Intense Emotional Distress:

If any of these situations currently apply to you, please explain:

Suicidal thoughts, plans, attempts:

Homicidal thoughts, plans, attempts:

Desire to cause pain to self or others:

In fear for your life or personal safety:

Too depressed to care for self or family:

I affirm that the information given on this form is true and complete


If this form has been completed for a minor, please give your name and relationship:

Script by Dagon Design