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1 Providence Biblical Counseling Ministry - Personal Data Inventory Identification Data: 1. Name: 2. Phone: 3. Date: 4. Address/City/Zip: 5. Occupation: 6. Business Phone: 7. Cell Phone: Birth Date: 10. Sex: Male Female 11. Age: 12. Marital Status: Single Engaged Married Separated Divorced Remarried Widowed 13. Education: Elementary High School GED College Graduate Degree: 14. Other Training (List type and years): 15. Hobbies: 16. Referred to us by: Relationship: 17. If you were raised by anyone other than your own parents, briefly explain: 18. How many siblings do you have? Older brothers: Sisters: Younger brothers: Sisters: Marriage Information: 19. Name of Spouse: Address: Occupation: Phone: Age: Business Phone: Religion: Education: 20. Does your spouse know you are coming to counseling? Yes No 21. Is your spouse willing to come to counseling? Yes No Uncertain 22. Have you ever been separated? Yes No When? From: Until: 23. Your ages when married: Husband: Wife: Wedding Date: 24. How long did you know your spouse before marriage? 25. Length of steady dating with spouse: Length of engagement: 26. Give brief information about any previous marriages: 27. Information about children: *(Indicate if by previous marriage under status) Status Name Birth Date Sex Currently Living? Education Marital Status

2 History Information: 28. Have you ever had a severe emotional upset? Yes No 29. Have you ever had any psychotherapy or counseling before? Yes No If yes, list counselor(s) or therapist(s) and dates: What was the outcome? 30. Check any of the following words which best describe you now: active ambitious self-confident persistent anxious hardworking impatient impulsive moody often sad excitable imaginative calm serious easy going shy fearful introvert extrovert likeable leader quiet inflexible submissive sensitive lonely self-conscious bitter angry 31. At any time have you: Felt people were watching you? Yes No Had difficulty recognizing faces? Yes No Been unable to judge distance? Yes No Had visual hallucinations? Yes No Had auditory (hearing) hallucinations? Yes No 32. List fears you have: 33. Have you ever been arrested? Yes No Reason: Health Information: 34. Approximately how many hours of sleep do you get each night? 35. When do you go to sleep at night? When do you get up? 36. Rate your health: Very Good Good Average Declining Other 37. Your approximate: Weight Height 38. Weight changes recently: Lost Gained 39. List all important present and past illnesses, injuries, or handicaps: _ 40. Date of last medical examination: What was the report: Providence PDI 2 Revised: January - 07

3 41. Name and address of your physician: 42. Are you presently taking medication? Yes No What 43. Have you used drugs for other than medical purposes? Yes No What 44. Are you willing to sign a release of information form so that your counselor may write for social, psychiatric, or medical reports? Yes No Religious Background 45. Denominational preference: 46. What church do you attend? City: 47. Who is your pastor? 47. May we contact your pastor for background information? Yes No 49. Number of church services you attend per month? (circle) Church attended in childhood: 51. Have you been baptized? Yes No 52. Religious background of spouse: 53. Do you believe in God? Yes No Uncertain 54. Do you pray to God? Yes No Occasionally 55. Would you say that you are a good person? Yes No Uncertain 56. Suppose you died today and God asked you Why should I let you into my heaven? What would you say? 57. Are you active in a Bible study or Sunday School Class or group? Yes No Name of Class 58. How much do you read the Bible? Often Never Occasionally 59. Does your family regularly read the Bible and pray together? Yes No 60. Explain any recent changes in your religious life, if any? Providence PDI 3 Revised: January - 07

4 Five Basic Questions Briefly answer the following questions: 1. What is your problem? 2. What have you done about it? 3. What do you want us to do? (What are your expectations in coming here?) 4. What brings you here at this time? 5. Is there any other information we should know? Providence PDI 4 Revised: January - 07

5 Providence Biblical Counseling Ministry INFORMED CONSENT FORM Our Goal: The purpose of Biblical Counseling is to help you meet the challenges of life in a way that will please and honor the Lord Jesus Christ. We offer counseling free of charge, as a ministry of the Providence Church. Counselees may donate to the ministry, but this is not expected or required as a condition of counseling. You have no express or implied obligation to pay fees for the counseling you receive through this ministry. Biblical Basis: Our counseling is strictly religious in nature, conducted under the authority and leadership of the church. We believe that God, through His revelation in the Old and New Testaments of the Bible, has provided His people with thorough guidance and instruction for faith and life (II Timothy 3:16-17; II Peter 1:3-4). Our counseling is based solely on scriptural principles. Our counselors are not trained or licensed as psychotherapists or mental health professionals, and under state law no such licensing is required. Other Professional Advice: If you have significant medical, legal, financial, or other technical questions, you should seek advice from a competent independent professional. Our counselors will cooperate with such advisors and help you to consider their counsel in the light of scriptural principles. More specifically, we urge our counselees to properly care for their physical bodies and to seek proper medical treatment for all physiological problems. Our counselors will assist you in responding to such problems in a godly manner, but our counsel is not intended to replace the services of a qualified physician where organic problems are present or where medication has been prescribed. Confidentiality: Confidentiality is an important aspect of the counseling process. We will carefully guard the information you entrust to us to the fullest extent possible. There are times, however, when it may be necessary for us to share certain information with others. Examples include, but are not limited to, the following: 1. Where a counselor is uncertain as to how to address a particular counseling issue, he may seek advice from a pastor/elder or another counselor. 2. Where a person refuses to renounce a particular sin, it may be necessary to seek the assistance of others in the church to encourage repentance and reconciliation (Proverbs 15:22, 24:11; Matthew 18:15-20). In such cases, we will reveal only such information as is necessary for such purposes; and only to those biblically required to be involved. Where a counselee is a member of another church, it may be necessary to contact the pastor of such church. 3. The counselor is required to inform local authorities of unreported cases of spousal or child abuse, as well as cases in which, in his/her estimation, I am in danger of committing suicide or of carrying out murderous threats.

6 Providence Biblical Counseling Ministry 4. Where a counselee threatens harm to another person, it may be necessary to intervene in order to prevent harm. 5. Observers may sit in on counseling sessions, either to assist in the process or for training purposes. Release of Liability: I declare I am fully capable of discerning good and bad advice, and I do not hold my counselor, Providence Church, or any other associated ministry or organization liable for any negative results from my participation in these sessions or from following my counselor s guidance. Cancellation Policy: I understand that if I cancel without good cause for two consecutive appointments that my time slot will go to someone else and I must go to the bottom of the waiting list. Not showing up constitutes canceling. Having clarified the principles and policies of our counseling ministry, we welcome the opportunity to minister to you in the name of Christ and to be used by Him as He helps you grow in spiritual maturity and prepares you for usefulness in His body. If you have any questions about these guidelines, please speak with your counselor. Your signature below indicates your informed consent to these guidelines. Printed Name: Signature: Date: Signature of Counselor: Date: Please send this Personal & Confidential to: Jack Enter Providence Church 2146 Buford Highway Duluth, GA Providence PDI 6 Revised: January - 07

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