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Personal Data Inventory
Identification Data Date:
1. Name: _______________________________________________2. Phone: ____________________
3. Address/City/Zip:
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4. Email:_____________________________________________________________________________
5. Occupation: ___________________________________ 6. Business phone: ____________________
7. Birth Date: ______________ 8. Sex: Male Female 9. Age: _________________
10. Marital Status: Single Engaged Married Separated Divorced Remarried Widow
11. Education: Elementary High School GED College Graduate Degree:____________
12. Other Training (List type and years):____________________________________________________
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13. Hobbies: _________________________________________________________________________
14. Referred to us by: _____________________ Relationship: _________________________________
15. If you were raised by anyone other than your own parents, briefly explain: _____________________
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16. How many siblings do you have? Older brothers: ___ Sisters: ___ Younger brothers: ___ Sisters: ___
Marriage Information:
17. Name of Spouse: ____________________________ Address: ______________________________
Occupation: _______________________________ Phone: _____________________ Age: ______
Business Phone: _________________ Religion: _________________ Education: ______________
18. Does your spouse know you are coming for counseling? Yes No
19. Is your spouse willing to come to counseling? Yes No Uncertain
20. Have you ever been separated? Yes No When? From: ___________ Till: __________
21. Your ages when married: Husband: _________ Wife: ___________ Wedding Date: ____________
22. How long did you know your spouse before marriage? ________________________
23. Length of steady dating with spouse: _____________ Length of engagement: ______________
24. Give brief information about any previous marriages: _____________________________________
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25. Information about children:
*(PM) NAME BIRTHDATE SEX LIVING ? EDUCATION MARITAL STATUS
*this colmn if child is by a previous marriage yes/no
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CURRENTLY