Personal Data Inventory (PDI) — Denver Counseling and Coaching

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.

Identification

Name *

Name

First Name

Last Name

Date of birth *

Date of birth

MM

DD

YYYY

Sex *

Male

Female

Address *

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone # *

Phone #

(###)

###

####

Email Address *

Marital Status *

Single

Married

Divorced

Widowed

Who referred you?

Only if applicable

Employment & Education

Are you currently employed? *

Yes

No

Employer, Position and Years Employed

If you answered yes above, please list your employer, position, and years employed in that position

Education

In Case of Emergency

Contact name *

Relationship to you *

Contact phone # *

Contact phone #

(###)

###

####

Marriage & Family

Spouse name

Leave blank if not applicable

Spouse date of birth

Spouse date of birth

Leave blank if not applicable

MM

DD

YYYY

How long have you been married?

Leave blank if not applicable

Spouse occupation

Employer

Years employed in current occupation

Spouse phone #

Spouse phone #

(###)

###

####

Brief description of how you met and length of relationship

Have you been married before

Yes

No

If you answered yes above, who and when?

Have you ever been separated?

Yes

No

If yes, when?

Children & Parents

Do you have children?

Yes

No

If yes, names, ages and sex:

Are they from prior marriage?

Yes

No

Are they adopted?

Yes

No

Are your parents living? *

Where do they live?

Describe your relationship with your father:

Good/Bad/Other

Describe your relationship with your mother:

Good/Bad/Other

Number of brothers: *

Number of sisters: *

Your place in order: *

Health

How would you rate your health: *

Good/Bad/Other

Any illnesses, injuries, conditions, and/or handicaps? *

Current medications and dosages: *

Please list, or put "none"

Have you ever used recreational drugs? *

Yes

No

If yes, please explain:

Date of last exam: *

Date of last exam:

MM

DD

YYYY

Physician's name

Physician's address

Physician's address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

How much alcohol do you drink? *

How much coffee do you drink? *

None/some/a lot

Do you smoke? *

Yes

No

If yes, how much?

Miscellaneous

Have you ever been arrested? *

Yes

No

Have you ever had interpersonal problems on the job? *

Yes

No

If yes, please explain:

Have you ever seen a psychiatrist or counselor? *

Yes

No

If yes, please explain:

Is your spouse willing to come to counseling?

Yes

No

Are they in favor of you coming?

Yes

No

Explain if needed:

Problem area checklist

Spiritual

Do you believe in God? *

Yes

No

Are you a Christian?

Yes

No

If yes, what is your denominational preference?

Church you attend:

Years/time attended:

Are you a member of your church?

Yes

No

Monthly attendance:

One

Two

Three

Four or more

Have you been baptized? *

Yes

No

When were you baptized?

How often do you read The Bible? *

Never

Sometimes

Often

Daily

How often do you pray? *

Never

Sometimes

Often

Daily

Please explain any changes in your spiritual life:

Final Questions

What are you seeking counsel for? *

Have you taken any action to solve this problem? *

Yes

No

If yes, please explain:

What benefits are you expecting from counseling? *

Is there anything else we need to know?

DCC Counselor you are scheduled with or prefer: *