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:______________________________________________
_______________________________________________________________________________________________
Your Physician ______________________________ Address________________________________________________
Are you presently taking medication? Yes___ No___ If yes, explain: _______________________________________________
_______________________________________________________________________________________________
Have you used drugs for other than medical purposes? Yes___ No___
If yes, explain:_____________________________________________________________________________________
_______________________________________________________________________________________________
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? ______________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
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
Cornerstone Bible Church 