Personal Data Inventory (Age 18 and over)

Are you a member at Saylorville Church? *

Please note, due to the number of requests for counseling we receive, we will give first priority to counseling those who are active members at Saylorville.

Yes

No

Are you currently in a Community Group? *

Yes

No

How many times per month do you attend Sunday morning services? *

IDENTIFICATION DATA

Phone Number *

Address *

Birthday *

Age *

Gender *

Marital Status *

Place of Business & Occupation *

Education Completed *

Referred By *

HEALTH INFORMATION

How would you rate your current physical health? *

If you select "Other," please specify in the box provided.

List all important past or present illnesses, injuries or handicaps *

Date and results of last medical examination? *

Physician's Name *

Personal Health History *

Check all that apply

I have had a severe emotional upset.

I have or have had a problem with alcohol or drug abuse (prescription or non-prescription).

I have been physically abused as a child.

I have been physically abused as an adult.

I have been sexually molested as a child.

I have been sexually molested, as an adult.

I have seen a psychologist, psychiatrist and/or counselor.

I have used drugs other than for medical purposes.

None of the above

If you have seen a psychologist, psychiatrist and/or counselor, please list the counselors or therapists, the dates you have been and the outcome. *

Have you ever been arrested? *

Check one

Yes

No

Are you presently taking any prescribed medication? *

Please check one.

Yes

No

Are you presently taking over the counter medication? *

Please check one.

Yes

No

Have you used drugs for other than medical purposes? If yes, what? *

Do you have or have you had a problem with alcohol or drug abuse (prescription or non-prescription)? *

Are you willing to sign a release of information so that your counselor may write for social, psychiatric or medical report? *

Yes

No

RELIGIOUS BACKGROUND

Did you attend church as a child? *

Check One

Yes

No

Have you trusted Jesus Christ as your personal Lord and Savior? *

Have you been baptized? *

Explain any significant religious changes in your life, if any? *

How would you describe your personal relationship with Jesus Christ? *

How often do you read the Bible? *

Does your family regularly read the Bible together? *

Do you practice other spiritual disciplines: Bible memorization, Bible meditation, personal prayer, journaling, witnessing or fasting? If so, please explain which and how often. *

SOCIAL MEDIA AND TECHNOLOGY PRACTICES

What are your social media practices? *

What platforms, apps or games do you regularly use? (Include All) *

How many hours per day are you on your phone or other electronic device? *

Have you ever struggled with addictions or depression as a result? *

MARRIAGE INFORMATION

Are you married? *

Yes

No

Do you have any children? *

Yes

No

Information about children *

Please list the names, ages, genders.
Please indicate if any of these children are married or are deceased.
Please indicate the level of education that these children individually possess in year.
Please indicate if any of these children are from a relationship other than a current marriage.

PERSONAL HISTORY

Were you reared by anyone other than your parents? *

Do you have older brothers and/or sisters? If yes, how many of each? *

Do you have younger brothers and/or sisters. If yes, how many of each? *

Have there been any deaths in the family during the last year? If yes, who and when? *

What is your relationship like with your parents, in-laws, children and siblings? *

Select any of the following words that best describe you now. *

Persistent

Ambitious

Self-Confident

Sensitive

Nervous

Hard-working

Impatient

Impulsive

Often Blue

Excitable

Imaginative

Calm

Serious

Shy

Easy-going

Good-natured

Introvert

Extrovert

Moody

Quiet

Determined

Submissive

Likable

Lonely

Dramatic

Self-conscious

Leader

Other

Do you have problems sleeping? If yes, please explain *

How many hours of sleep do you average each night? *

BASIC INFORMATION

What is the main problem, as you see it? *

What brings you to the point of wanting to meet with a counselor

What have you done about it? *

What can we do? What are your expectations in meeting with a counselor? *

Is there any other information we should know? *

WHAT IS NEXT?

After completing this form, you will receive a confirmation email with a link to our Consent to Counsel form. Once you've completed both the PDI (this form) and the Consent to Counsel, your request for counseling will be entered into our scheduling queue.