Counseling Request (Personal Data Inventory #A)

Counseling Request

(Personal Data Inventory #A)

(Please complete this inventory carefully) Date________________

Personal Identification:
Name ______________________________________________________Birth Date _______________

Address___________________________________________________________Zip_______________

Cell or home phone ____________________________________________ Age______ Gender______

In case of emergency, please contact (name & number):_________________________________________________

Marriage and Family:

Marital Status: Single Engaged Married Separated Divorced Widowed

Spouse _______________________________________________Birth Date ____________________

Age _____ Home Phone _____________________________Business Phone_____________________

Date of Marriage ___________________________Length of dating ____________________________

Give brief statement of circumstances of meeting and dating __________________________________

___________________________________________________________________________________

Have either of you been previously married __________ To Whom ____________________________

Information about your children:

Name Age Sex Living Yrs. Ed. Step-child

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________

Church:

Church attending ? _______________________No. of times/month? 1 2 3 4 5 6 7 8+

Referred By (How did you hear about us?)__________________________________________________

Does your pastor know you are seeking counsel here? Y N Is there a reason you would rather not talk to him?_____________________________________________________________________________

Education and Career:

Education: (last year completed): __________________School___________________________________

Employer ______________________________________Business Phone _______________________

Position _______________________________________ How long? ___________________________

Briefly Answer the Following Questions:

1. What is the problem or concern that brings you here today? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

2. What attempts have you made to resolve this problem?

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________
3. What are your expectations from counseling?

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

4. Is there any other information we should know about (For example: What has happened recently?)?

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

NorthCreek Church Biblical Counseling Ministry (February 2013) Please return to the Biblical Counseling Office in one of the following ways: Fax [phone]), scan and email ([e-mail]), drop off, or snail-mail to: NorthCreek Church, Attn: BCM, 2303B Ygnacio Valley Rd, Walnut Creek, CA 94598

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