Personal Information Form (PIF)

Personal Information Form (PIF) 

Robert D. Jones, D. Theol., D.Min.

 

Name________________________________________  Gender___   Age___   Date_______________

Address _________________________________________________  Email ____________________

(Street/Box)                                       (City)                     (State/Zip)

Daytime telephone ______________ Evening telephone ___________  Referred to us by ___________

Section I — Marital Status/History

Status (underline all that apply): Single  Engaged  Married  Separated   Divorced   Widowed

Your Present Marriage (if applicable):

Spouse’s name _________________________  Age ___  Spouse’s occupation ___________________

Date of marriage _______  Place _____________ Years married ___

If you and your spouse have ever separated, give dates and circumstances: ______________________

__________________________________________________________________________________

Rate your marriage (circle: 0 terrible, 5 excellent):   0   1   2   3   4   5.   What might make it better?

__________________________________________________________________________________

__________________________________________________________________________________

Children from Present Marriage (if applicable):

Name            Son/Daught.    Age      Where Live           Marital Status         Occupation

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

Your Previous Marriages (or Relationships that Produced Children) (if applicable):

Name of Spouse/Partner    Dates                Children (Names and Ages)

1.  __________________  _____to_____  ________________________________________________

2.  __________________  _____to_____  ________________________________________________

Has your spouse been previously married? ___   How many times? ___

Children (Names and Ages) ___________________________________________________________

 

 

Section II — Occupational Status/History

Education (last level completed) ________   School/Institute _________________________________

Occupation _____________________  Name of Company ___________________  City/State ______

# Years there ______   Present income (est.) $_________  Work Telephone (____)________________

Does your present work satisfy you? Explain: _____________________________________________

__________________________________________________________________________________

What other job positions have you held in the past? _________________________________________

__________________________________________________________________________________

Section III — Family of Origin History

Parents:  Name                  Age    Where Live    Marital Status       Occupation

Father: ____________________________________________________________________________

Mother: ___________________________________________________________________________

Guardian: _______________  Relation to you: __________  Dates: _________

Brothers/Sisters:  (List in order from oldest to youngest; include yourself in that order):

Name           Bro/Sis/Step  Age   Where Live    Marital  Status    Occupation

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

Family “Climate”: Describe your home life during your childhood and teen years: ________________

__________________________________________________________________________________

__________________________________________________________________________________

Indicate any problems you experienced as a child or teen:

Family problems___  School problems___  Emotional/behavior problems___   Legal problems___   Medical problems___  Social problems___ Drug/alcohol problems___  Other:____________________

Psychological Problems: Have you, or any parent or brother or sister, been hospitalized or received professional help for “psychological” problems? Specify person, dates, and problem: ______________

__________________________________________________________________________________

__________________________________________________________________________________

Section IV — Religious Status/History

Past Denominational Background _______________  Present Denom. Preference_________________

Church Presently Attending __________________________________  City & State ______________

Member:  Yes  No        Average # of times per month you attend ___

Pastor ___________________ Telephone ______________  Permission to contact him: Yes  No

Do you believe in God?  Yes  No  Unsure

Do you consider yourself “saved?”   Yes   No   Unsure   Don’t understand the term

How frequently do you pray?  Often  Occasionally  Rarely  Never

How frequently do you read the Bible?  Often  Occasionally  Rarely  Never

What is your view of the Bible? ________________________________________________________

Have you come to the place in your spiritual life where you know for certain that if you were to die today you would go to heaven?  Yes  No  Unsure

Suppose you were to die and stand before God and he were to say to you, “Why should I let you into my heaven?,” what do you think you might say to God? _____________________________________

__________________________________________________________________________________

Why do you desire Christ-centered, biblical counseling? _____________________________________

__________________________________________________________________________________

Explain any recent changes in your religious life:  __________________________________________

__________________________________________________________________________________

Section V — Medical Status/History

Rate your health:  Very Good __  Good __  Average __  Poor __     Recent Problems? __________________

Date of last medical exam: __________  Report ___________________________________________

Your Physician ____________________________________________ City & State_______________

List any prescription medications you take:

Medication                 Treatment for               When began     Daily dosage           Prescribing Physician

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

List over-the-counter medications you currently take (diet pills, laxatives, birth control pills, cold and allergy medicines, aspirin, etc.): __________________________________________________________

__________________________________________________________________________________

List any surgeries that required anesthesia: ______________________________________________

__________________________________________________________________________________

Average daily caffeine consumption?  (coffee, tea, chocolate, stimulants, caffeinated soft drinks, etc.)  __________________________________________________________________________________

How often do you drink alcoholic beverages?   Often  Occasionally  Rarely  Never

How often do you struggle with the temptation to use illegal drugs?   Often  Occasionally  Rarely  Never

Average # of hours of sleep each night? ___  Is it restful? ____________________________________

Describe any recent changes in your sleep patterns: _________________________________________

__________________________________________________________________________________

Have you had any of the following physical problems?  Please check.

Heart problems ___                            Hypoglycemia ____                           Menstrual irregularities ___

Liver problems ___                             Lung Problems ____                           Hallucinations ____

Kidney Problems ___                         Allergies ______                                  Change in sexual drive ____

Head injury/concussion ___             Cancer ___                                           Problems walking ___

Stroke ____                                          Incoordination ___                             Unusual hair loss ___

Seizures ____                                       Anorexia or Bulimia  ___                  Rashes ___

Brain Tumor ____                              Visual Problems ____                         Memory Problems ____

Multiple Sclerosis ___                         Sensory distortions ____                    Episodic disorientation ___

Parkinson’s Disease ___                    Weakness ____                                   Personality change ____

Blackouts ____                                   Fatigue ____                                        Deja Vu ___

Amnesia ____                                      Heat/cold sensitivity ___                   Changes in consciousness ___

Tremors ____                                       Bowel/bladder problems ___            Headaches ____

Thyroid dysfunction ___                   Nausea or vomiting ___                     Dizziness ____

Diabetes ___                                        Recent weight change ____              Stiff neck ___

High Blood Pressure ___                    Impotence ___                                    Physical changes ___

Constant Hunger  ___                        Food cravings ___                               Fever ___

Pneumonia ___                                   Speech Problems ___                         OTHER? _________________________________

Have you or others noticed any changes in your personality (anger, mood swings, withdrawal), your thinking and memory, or your work habits? _______________________________________________

__________________________________________________________________________________

Section VI – Legal Actions (if applicable, for example, in conflict or separation/divorce cases)

If you have talked with an attorney about your problem, or intend to, please provide the following info:

Attorney                                                        Firm                                                                         

Address                                                                                             Phone                                  

     Date and purpose _______________________________________________________________

Has a legal action been filed or is one likely to be filed in this situation?  No  Yes  (If yes, give dates and describe action below.)

Other information that might be helpful for us to know about you (attach separate sheet if needed)

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