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Family Care Counseling Personal Data Inventory |
Instructions: This
confidential information form is for the use of your counselor. Please
complete it as
carefully as you can. If both husband and wife are coming for
counseling, each should fill out a form.
IDENTIFICATION DATA: Today’s Date:
Name:
Address:
City: State: Zip Code:
Email:
Home Phone: Work Phone:
Cell: Pager:
Sex: Birth date: Age: Height:
MARRIAGE INFORMATION: If never married, check and omit this section.
Marital Status: (check) SINGLE GOING STEADYENGAGEDMARRIED
Name of Spouse:
HOW DID YOU HEAR ABOUT OUR COUNSELING?
Are you presently taking medication? Yes:No: What:
Have you ever had a severe emotional upset? Yes: No: When:
PERSONALITY INFORMATION:
Have you ever had counseling before? No: Yes:When:
Number of Sessions:
INFORMATION ABOUT CHILDREN:
NAME AGE SEX LIVING EDUCATION MARITAL STATUS
What is your presenting problem?