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Biblical Soul Care Personal Data Inventory

This Personal Data Inventory is our way of getting to know you so we can best serve you. It is important to gather both past and present information. We want you to be as open and specific in your answers as possible. This will help us to be both prepared and effective in the counseling process.

Personal Information:

Personal Information:


Today's Date: (required)

First Name: (required)

Last Name: (required)

If not for yourself, for whom are you filling out this form?

Birthdate:

Current Age:

Email Address: (required)

Primary Contact Phone Number: (required)

Alternate Phone Number: (required)

Address:(required)

Address 2:

City:(required)

State:(required)

Zip Code:(required)

Country:(required)

Occupation:

You were referred to Biblical Soul Care by:

Who will you be contacting to serve as your advocate? (check advocate manual for more detailed info)

Their relationship to you?

Your Church Status

If Church Status was 'other,' explain:

How long have you been coming to Harvest?

Are you in a small group and if so, for how long?

Name of Small Group Leader/s:

Is there a leadership role that you currently hold or are considered for at Harvest?


Family Information


Marital Status *

Date of Marriage

Spouses Name:

Spouses Phone Number:

Have you ever been seperated?

If yes, how many times and how long?

Has either of you filed for divorce?

If 'yes,' who filed and when?

Have you been married previously?

If 'yes,' explain:

If you have children, please list their names, ages, and if applicable, their marital status:


Background Information


Other than your parent(s), was there any other significant role model growing up?

If 'yes,' explain:

Parenting is (was):
Authoritative: democratic style of parenting, parents are attentive, forgiving, teach their offspring proper behavior, have a set of rules, and if child fails to follow there is punishment, if followed there is reward/reinforcementAuthoritarian: strict parenting style, involves high expectations from parents but have little communication between child and parents. Parents don't provide logical reasoning for rules and limits, and are prone to harsh punishmentsPermissive: parents take on the role of "friends" rather than parents, do not have any expectations of child, they allow the child to make their own decisions.Disengaged:parents neglect their child by putting their own life before the child's. They do provide for the child's basic needs but they show little interaction with the child

Are (were) your parents divorced?

Was there abuse in your past?

If 'yes,' explain:

Was there substance abuse in your family?

If yes, explain:

Have you ever been arrested?

If yes, explain:

Have you recently had significant circumstances/events in your life (i.e. job loss, birth, death, etc.)??

If yes, explain:

Did you have any significant traumatic events as a child or have you ever had an extreme emotional reaction to a situation in your life?


Personality


Check each word that describes you:

Have you ever had any counseling or psychotherapy?

If yes, explain:


Faith Background


Have you put your faith in Jesus Christ as your Lord and Savior?

If yes,when?

How often are you in God's word?

How often do you pray?

Are you serving Christ at Harvest?

Has your spouse put his/her faith in Jesus Christ as their Lord and Savior?

If yes,when?


Briefly Answer the Following Questions:


From your perspective, what would you say is/are the problem(s) you want to address through counseling?

What have you done so far to address it/them?

How can we help? What are your expectations in coming to counseling?

What, if anything do you fear? (Regarding the problem or consequences thereof, such as fear of rejection, fear of losing my family, etc.)

Is there any other information your counselor should know?

What times would you be available for counseling?

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