Download Forms for Printing/Mailing

Please print out and mail completed forms (2 sets for couples; 3 sets for parent/s child) to:

(Or go to the “Fill-in Online Data” tab and get the info to us sooner)

Dr. Ron Tardif

30 Smolen Rd.

Denmark, Maine 04022

PERSONAL DATA INVENTORY

 

Today’s Date ______ / ______ / ______   Identification Data:

Name ___________________________________ Home Phone ___________________Cell ________________________

Street_______________________City________________State____Zip ______ Email ____________________________

Occupation ____________________________________ Business Phone _______________________________________

Sex______ Birth Date ______ / ______ / ____ Age ________ Height _________

Marital Status: Single___  Cohabiting ____ Married ___ Separated___ Divorced____ Widowed_____

Education (last year completed)______ (grade) Other training (list type and years) _____________________________________

_______________________________________________________________________________________________

Referred here by ________________________ Address _____________________________________________________

HEALTH INFORMATION:

 

Rate your health (check): Very Good___  Good___  Average___  Poor___  Very Poor___ Declining__________________________

Your approximate weight __________ lbs Weight changes recently:   Lost_________  Gained_____________________________

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

_______________________________________________________________________________________________

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Date of last medical examination ______ / ______ / ______ Report:______________________________________________

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Your Physician ______________________________ Address________________________________________________

Are you presently taking medication? Yes___ No___ If yes, explain: _______________________________________________

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Have you used drugs for other than medical purposes? Yes___ No___

If yes, explain:_____________________________________________________________________________________

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Have you ever had a severe emotional upset? Yes___ No___ If yes, explain:  __________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

Have you ever been arrested? Yes___ No___ If yes, explain: _____________________________________________________

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Are you willing to sign a release of information form so that your counselor may write for psychiatric or medical reports? Yes___ No___

Have you recently suffered the loss of someone who was close to you? Yes___ No___ If yes, explain: _______________________________________________________________________________________________

_______________________________________________________________________________________________

Have you recently suffered loss from serious social, business, or other reversals? Yes___ No___ If yes, explain _______________________________________________________________________________________________

_______________________________________________________________________________________________

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RELIGIOUS BACKGROUND:

 

Denominational preference: _______________ Member? Yes ___ No ___ Where? ­___________________________________

Church attendance per month (circle)  0   1   2   3   4   5  6   7   8   9   10+

Church attendance in childhood _______________ Baptized? Yes___ No___ Immersion? ______________________________

Religious background of spouse (if married) ________________________________________________________________

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___ Date of salvation ______ / ______ / ______

How much do you read the Bible? Never___ Occasionally___ Often______ Other _____________________________________

Do you have regular family devotions? Yes___ No___ Seldom ___________________________________________________

Explain recent changes in your religious life, if any:____________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

PERSONALITY INFORMATION:

 

Have you ever had any psychotherapy or counseling before? Yes___ No___

If yes, list counselor or therapist and dates: _________________________________________________________________

_______________________________________________________________________________________________

What was the outcome? ______________________________________________________________________________

Circle any of the following words which best describe you now: active ambitious self-confident persistent nervous hardworking impatient impulsive moody often-blue excitable imaginative calm serious shy easy-going good-natured introvert extrovert likable leader quiet hard-boiled submissive lonely self-conscious sensitive other:___________________________________________________________________________________________

_______________________________________________________________________________________________

Have you ever felt people were watching you? Yes___ No___

Do people’s faces ever seem distorted? Yes___ No___

Do you ever have difficulty distinguishing faces? Yes___ No___

Do colors ever seem too bright? _________ Too dull? _______________Normal___________

Are you sometimes unable to judge distances? Yes___ No___

Have you ever had hallucinations? Yes___ No___

Are you afraid of being in a car? Yes___ No___

Is your hearing exceptionally good? Yes___ No___

Do you have problems sleeping? Yes___ No___

Circle any of the following words which you have had associations:  channeling  necromancy

spirit-guides witchcraft  Ouija-board card-reading  use-of-crystals  astral- projection   psychic-powers  divination  fortune-telling  séances  devil-worship  hypnotism  Transcendental-Meditation(TM)

Briefly explain: ____________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

MARRIAGE AND FAMILY INFORMATION:

 

Name of spouse______________________________ Address________________________________________________

Your spouse’s phone__________________ Occupation_____________________ Business Phone_______________________

Your spouse’s age _____ Education (in years) _____ Religion ___________________________________________________

Is spouse willing to come for counseling? Yes___ No___ Uncertain ________________________________________________

Have you ever been separated? Yes___ No___ If yes, from  _____________________ to_______________________________

Has either of you ever filed for divorce? Yes___ No___ If so, when? ________________________________________________

Date of Marriage _________ Your ages when married:  Him_____ Her_____

How long did you know your spouse before marriage? _________________________________________________________

Length of steady dating with spouse?____________________ Engagement?_______________________________________

Give brief information about any previous marriages:__________________________________________________________

_______________________________________________________________________________________________

Information about children:

*PM            NAME                                            AGE     SEX   LIVING?    EDUCATION          MARRIED?

(* Check this column if child is by previous marriage. )

1 ____       ________________________________________________________________________________________

2 ____       _______________________________________________________________________________________

3 ____       _______________________________________________________________________________________

4 ____       _______________________________________________________________________________________

5 ____       _______________________________________________________________________________________

6 ____       _______________________________________________________________________________________

If you were reared by anyone other than your own parents, briefly explain: ____________________________________________

_______________________________________________________________________________________________

How many older brothers____________ sisters____________ do you have?

How many younger brothers__________ sisters____________ do you have?

BRIEFLY ANSWER THE FOLLOWING QUESTIONS:

 

1.What is your problem? ______________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

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2.What have you done about it? _________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

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3.What can we do (expectations)? ________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

4.As you see yourself, what kind of person are you? Describe yourself: _______________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

5.What, if anything, do you fear? ________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

6.Is there any other information we should know? _____________________________________________________________

_______________________________________________________________________________________________

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02/12