Chapel in the Hills - Personal Data Inventory

Personal Data Inventory

To help us more efficiently discern what we can do to help, we ask you to fill out the following form. If you are coming as a couple or family, each family member should complete a form separately. (If under the age of 12 no form is necessary.) Thank you.

First Name

Last Name

Birthdate

Primary Phone Number

Alternate Phone Number

Email

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Is the counseling for you? If not, who is the counseling for?

How would you like to receive appointment reminders?

Current Occupation

What day(s) of the week / time(s) of day are your best availability to meet?

How did you hear about us, or who referred you?

Marital Status:

Single

Married

Divorced

Divorced and re-married

Spouse (or former spouse's) Name(s)

Children & Ages (if applicable):

Do you have any physical or medical conditions? Please explain:

Do you take any medications? Please explain:

Do you attend church? What church do you regularly attend? Are you a member?

Please list any way(s) that you're currently involved at your local church:

If you were to die tonight and stand before God and He asked you why He should permit you to enter heaven, what would you answer? :

Who are your two closest friends and why?

Do you have a close Christian friend who, if needed, could come with you to the counseling for support, encouragement and accountability between sessions?:

Have you received counsel in the past? Who, when and for how long? Can you summarize what they believed the main problem to be and what they told you to do about it? :

1. What is the main problem/trouble as you see it? (i.e. What needs to change?)

2. What things do you think have contributed to the problem/trouble? Do you believe you have in some ways contributed to the problem/trouble? Explain:

3. Please describe anything you have done about this problem so far? What were the results?

4. What would you like us to do?