Christian Counseling

Lake City, FL

Rebekah Prewitt, MA
(407) 731-9998
rp@lakecitycounsel.com

INVENTORY DATA FORM

Please fill the form out completely. If something does not apply, write, N/A. After we receive the form, you will be contacted regarding an appointment.


Today's Date:

Identification Data

Name (First and Last):

Phone Number:

Email Address:


Date of Birth (month/day/year):

Gender: Male Female

Marital Status (Married, Divorced, Single, Separated, Widowed):

Address (Street, City, State, Zip Code):


Job Title:

Company's Name:

Work Hours:

Days Off:


Education (highest level completed):


May we text or email you between sessions if need be? Yes No

Problem

Briefly answer the following questions.

1. What is your problem?


2. What have you done about it?


3. What can we do? (What are your expectations in coming here?)


Religious Background

Church You Attend:

Church Attendance Per Month (1, 2, 3, 4, 5,6, 7, 8, 9, 10+):

Do you consider yourself a religious person? Yes No Uncertain

Do you believe in God? Yes No Uncertain

Do you pray to God? Never Occasionally Often

Are you saved? Yes No Not sure what you mean

Were you baptized by water immersion? Yes No Not sure what you mean

How much do you read the Bible? Never Occasionally Often

Do you have regular family devotions? Yes No

Explain recent changes in your religious life, if any:

Father's religious background:

Mother's religious background:

Do you belong to any clubs or organizations? Yes No

List the name(s) of the organizations:

Health Information

Rate your health (Very Good, Good, Average, Declining):

List all important present or past illnesses, injuries or handicaps:


Are you presently taking medication? Yes No

List the medication(s) you are taking and the reason:


Have you are or are you currently using drugs for other than medical purposes? Yes No

If yes, what drug(s)?

Have you recently suffered the loss of someone who was close to you? Yes No

Have you recently suffered loss from serious social, business, or other reversals? Yes No

Personality Information

Have you ever had any psychotherapy or counseling before? Yes No

If yes, list counselor/therapist and the dates:


What was the outcome?

Marriage and Family Information

Please write N/A if unmarried.

Name of Spouse:

Spouse Phone Number:

Spouse Occupation:

Spouse Age:

Spouse Education (highest level completed):

Spouse Religion:

Is your spouse a saved person? Yes No Uncertain

Is your spouse willing to come for counseling? Yes No Uncertain

Have you ever been separated? Yes No

Has either of you ever filed for divorce? Yes No

Date of Marriage

Religious Background of Spouse's Parents:

1. Father

2. Mother

Information About Children:

Please list children's names, age, marital status, and their connection to you
PM=Previous Marriage, AD=Adopted, FO=Foster, (Example: Mary Smith, 15, Single, FO)


Referred by (internet, newspaper, friend, spouse, other, etc.):