Personal Data Inventory (PDI)

In order for us to best serve you, we need to know some information about you. This form is to be filled out entirely before your first visit.

Name *
Date of birth *
Date of birth
Sex *
Address *
Phone # *
Phone #
Marital Status *
Only if applicable
Employment & Education
Are you currently employed? *
If you answered yes above, please list your employer, position, and years employed in that position
In Case of Emergency
Contact phone # *
Contact phone #
Marriage & Family
Leave blank if not applicable
Spouse date of birth
Spouse date of birth
Leave blank if not applicable
Leave blank if not applicable
Spouse phone #
Spouse phone #
Have you been married before
Have you ever been separated?
Children & Parents
Do you have children?
Are they from prior marriage?
Are they adopted?
Please list, or put "none"
Have you ever used recreational drugs? *
Date of last exam: *
Date of last exam:
Physician's address
Physician's address
None/some/a lot
Do you smoke? *
Have you ever been arrested? *
Have you ever had interpersonal problems on the job? *
Have you ever seen a psychiatrist or counselor? *
Is your spouse willing to come to counseling?
Are they in favor of you coming?
Problem area checklist
Do you believe in God? *
Are you a Christian?
Are you a member of your church?
Monthly attendance:
Have you been baptized? *
How often do you read The Bible? *
How often do you pray? *
Final Questions
Have you taken any action to solve this problem? *