CompassPoint Biblical Counseling
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compasspoint biblical counseling
PERSONAL DATA INVENTORY FORM
Please complete the following 4-part form, and click submit when completed. It should take about 10-minutes to complete.
Part 1 - Personal Information
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Indicates required field
First and Last Name
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DATE OF BIRTH
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STREET
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CITY
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STATE
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ZIP CODE
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E-MAIL
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Phone Number
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Gender
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PLEASE SELECT
Male
Female
Education
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High School
Some College
Undergraduate Degree
Graduate Degree
Doctoral Degree
Marital Status
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Single
Engaged
Married
Separated
Divorced
Widowed
Remarried
Spouse's Name
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Spouse's Occupation
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Spouse's Phone
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Spouse's Religion
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Spouse's Age
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# Years Married
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is your spouse aware you want counsel?
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PLEASE SELECT
Yes
No
Maybe
is your spouse willing to come with you?
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PLEASE SELECT
Yes
No
Maybe
list children name, gender, and age
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Please list any children, gender, and age below:
Part 2 - Religious Information
CHURCH NAME
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PASTORS NAME AND PHONE NUMBER
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MAY WE CONTACT YOUR PASTOR?
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Yes
No
MONTHLY CHURCH ATTENDANCE
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Less than 2 times per month
3-4 times per month
5-8 times per month
More than 9 times per month
Do you believe in God?
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PLEASE SELECT
Yes
No
Maybe
DO YOU BELIEVE YOU ARE SAVED?
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PLEASE SELECT
Yes
No
Maybe
HAVE YOU BEEN BAPTIZED?
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PLEASE SELECT
Yes
No
DO YOU PRAY REGULARLY?
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PLEASE SELECT
Yes
No
DO YOU READ THE BIBLE REGULARLY?
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PLEASE SELECT
Yes
No
CERTAIN YOU WILL GO TO HEAVEN?
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PLEASE SELECT
Yes
No
Part 3 - Health Information
date of last medical examination
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outcome of examination
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Will you sign a medical release?
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PLEASE SELECT
Yes
No
Doctor's Name and Phone Number
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Do you take any medications?
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PLEASE SELECT
Yes
No
Please list medications
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Do you use drugs or alcohol?
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PLEASE SELECT
Yes
No
please list drugs or alcohol
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PLEASE RATE YOUR HEALTH
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PLEASE SELECT
Very Satisfied
Satisfied
Unsatisfied
Very Unsatisfied
HOW MANY HOURS OF SLEEP DO YOU GET?
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PLEASE SELECT
Less than 3 hours
3-5 hours
6-7 hours
7-9 hours
More than 10 hours
have you been to counseling before?
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PLEASE SELECT
Yes
No
counselor name and phone
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PRESENT LEVEL OF LIFE SATISFACTION
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PLEASE SELECT
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
HAVE YOU EVER HAD EMOTIONAL UPSET?
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PLEASE SELECT
Yes
No
Not sure
DO YOU HAVE THOUGHTS OF SELF HARM?
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PLEASE SELECT
Yes
No
DO YOU HAVE SUICIDAL THOUGHTS?
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PLEASE SELECT
Yes
No
PLEASE LIST ANY FEARS YOU HAVE
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PLEASE LIST ANY CONCERNS YOU HAVE
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PLEASE LIST ANY PHYSICAL CONCERNS
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PLEASE LIST ANY SPIRITUAL CONCERNS
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PLEASE LIST ANY PERSONAL CONCERNS
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PLEASE LIST ANY RELATIONAL CONCERNS
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Part 4 - Present Issues
1. WHAT BRINGS YOU IN TODAY?
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2. WHAT ARE YOU SEEKING HELP FOR?
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3. what have you done about it?
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4. what do you hope to accomplish?
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5. anthing else you wish us to know?
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Thank you for completing this form.
If you are satisfied with your answers, please submit your form by clicking below.
Submit Form
You may now click the button below to schedule your appointment online.
Schedule Appointment Online
Home
Services
Begin Here
NEW COUNSELEE FORM
Schedule Online
About
Know Jesus
Donate