Personal Data Inventory – Grace Baptist Church

Personal Data Inventory Form

Please fill out the information below.

1. Name *

First

Last

2. Email *

3. Phone Number

4. Address, City, State, Zip

5. Occupation

6. Employer

7. Gender

Male
Female

8. Birthdate, Age

9. Referred here by:

10. Have you ever received counseling at Hope Biblical Counseling Center?

12. Have you ever used drugs other than for medical purposes?

Yes
No

If yes, please explain why.

13. Have you ever been arrested?

Yes
No

If yes, please explain why.

14. Have you recently suffered the loss of someone who was close to you?

Yes
No

If so, when? Please explain:

15. Do you have problems sleeping?

16. Education (last grade or degree completed):

17. Other training (list type and years, including degrees):

18. Spouse's Name

First

Last

19. Spouse's Occupation

20. Spouse's Phone Number

21. Spouse's Age

22. Spouse's Education (last grade or degree completed)

23. Date of Marriage. You and your spouse's age of marriage.

24. Would your spouse be willing to come for counseling?

Yes
No
Uncertain

25. Religious background of spouse:

26. Have you ever been separated?

Yes
No

If so, when?

27. Have you ever filed for divorce?

Yes
No

If so, when?

28. Give brief information about any previous marriages:

29. Do you have any children?

Name, Age, Gender, from a previous marriage?

30. How many siblings do you have and which number are you?

31. What is your parents' marital status?

32. What church are you a member of? Are you currently attending?

33. How long have you been attending? How often?

34. What church did you attend as a child?

35. Do you consider yourself a religious person?

Yes
No
Uncertain

36. Do you believe in God?

Yes
No
Uncertain

37. Do you believe Satan exists?

Yes
No
Uncertain

38. Have you ever "dabbed" with the "Occult" (seances, devil worship, witcraft, etc.)?

Yes
No

40. Would you say that you are a Christian?

Yes
No
Or would you say that you are still in the process of becoming a Christian?

41. How often do you read the Bible?

Never
Occasionally
Often

42. Do you have a regular time of devotions?

Yes
No
I'm not sure what that means

43. Explain recent changes in your religious life, if any?

44. What was your religious experience as a child? What was your home environment like in regards to Christianity, the Bible, and the Church?

45. Who have you spoken to about this issue and what has happened as a result?