GCC Biblical Counseling Ministry Personal Data Inventory (PDI)

Please complete this inventory carefully

Your name *

Last name

Email address *

Personal Identification

Birthdate

Address

HomeWorkOther

Country

Country

Street Address

Apt/unit/box (optional)

City

State

Postal code

Gender

Select…MaleFemale

Referred by

Marital Status

Single

Engaged

Married

Separated

Divorced

Widowed

Education

(last year completed)

Phone number

Phone type

MobileHomeWorkOther

Employer

Position

Years

Marriage & Family

Household members

+ Add adult+ Add child

Spouse occupation

How long has spouse been employed

Date of marriage

Length of dating

Give a brief statement of circumstances of meeting and dating

Have either of you been previously married, if so to whom

Have you ever been separated or filed for divorce

Describe relationship to your father

Describe relationship to your mother

Number of sibling(s)

Your sibling order

Did you live with anyone other than parents

Are your parents living

Do they live locally

Health

Describe your health

Do you have any chronic conditions, if so what

List important illnesses and injuries or handicaps

Date of last medical exam

Report

Physician's name and address

Current medication(s) and dosage

Have you ever used drugs for anything other than medical purposes

If yes, please explain

Have you ever been arrested

Do you drink alcoholic beverages

If so, how frequently and how much

Do you drink coffee and/or other caffeine drinks, and if so how much

Do you smoke, if so what, and how frequently

Have you recently suffered the loss of someone who was close to you

Select…YesNo

If yes, explain

Have you ever had interpersonal problems on the job

Have you ever had a severe emotional upset, if yes, please explain

Have you ever seen a psychiatrist or counselor, if yes, please explain

Are you willing to sign a release of information form so that your counselor may write for social, psychiatric, or other medical records

Spiritual

Denominational preference

Church attending, and are you a member

Church attendance per month, including community groups

Select…012345678+

Do you believe in God

Do you pray

Would you say that you are a Christian

Or still in the process of becoming a Christian

Have you ever been baptized

How often do you read the Bible

Select…NeverOccasionallyOftenDaily

Do you have regular devotions

Select…YesNoNot sure what you mean

Explain any recent changes in your religious life

What church did you attend as a child

Religious background of spouse (if married)

Do you consider yourself a religious person

Select…YesNoUncertain

Do you believe in God

Select…YesNoUncertain

Do you believe Satan exists

Select…YesNoUncertain

Have you ever "dabbled" with the "Occult" (Séances, devil worship, witchcraft, etc.)

Select…YesNoUncertain

Do you pray to God

Select…YesNoNeverOccasionallyOften

Are you in a community group, if so who are your CG leaders

Are you in a discipleship relationship, if so with whom

*Women Only

Have you had any menstrual difficulties

Is your husband willing to come for counseling

Is he in favor of you coming, if no, please explain

Problem Check List

Check all that would apply as problems in your life

Anger

Anxiety

Apathy

Appetite

Bitterness

Change in lifestyle

Children

Communication

Conflict (fights)

Deception

Decision Making

Depression

Drunkenness

Envy

Fear

Finances

Gluttony

Guilt

Health

Homosexuality

Impotence

In-laws

Loneliness

Lust

Memory

Moodiness

Perfectionism

Rebellion

Sex

Sleep

Wife abuse

A Vice

Other

Briefly Answer the Following Questions

1. What is your problem (what brings you here)?

2. In what way(s) have you contributed to the problem?

3. What have you done about the problem?

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

5. What, if anything, do you fear?

6. What are your expectation from counseling?

7. Is there any other information that we should know?

Spiritual Convictions Questionnaire

Finish each sentence with brief statements

1. God is

2. Jesus Christ is (describe who you think He is, what He has done, what He is doing now, what place He has in your life, what He means to you, etc.)

3. My relationship to God and His Son, Jesus Christ is (describe the kind of relationship you have with God and how important that relationship is - be specific)

4. A Christian is

5. I know that I am (or am not) a Christian because

6. The Bible is (describe what you think it is, what it means to you, what place it has in your life, how you use it, etc.)

7. Sin is

8. My chief sins are

9. When I sin, I (describe how you handle sin, what you feel when you sin, what you do after you sin)

10. I feel guilty when

11. I pray (when, how, why, what for, etc.)

12. My chief goals in life are

13. I want (or do not want) to attend and be involved in church (answer the questions "how" and "why")

14. I believe community with other Christians is (define what it is, what it involves, how important it is, and how it can be developed)

15. I am promoting my spiritual growth and the spiritual growth of my spouse (if married) by

16. My spouse, future spouse, or friend and I differ in spiritual matters (when, how, over what, etc.)

17. The changes I would like to make in my own spiritual life are

18. The changes I would like my spouse (or future spouse) to make spiritually are

Gospel Collective Church Consent to Biblical Counseling

Biblical Counseling: The goal of biblical counseling is to help you meet the challenges of life in a way that will please and honor the Lord Jesus Christ and allow you to fully enjoy His love for you and His plans for your life.

Not Secular Advice: This is a biblical counseling/discipling ministry and not professional counseling. We do not provide the same kind of professional advice and services that a licensed psychologist or certified counselor would when hired in a professional capacity. Therefore, if you have significant legal, financial, medical, or other technical questions, you should seek advice from independent professionals. We would be happy to cooperate with such advisors and help you to consider their counsel in the light of relevant biblical principles. By signing this document, you agree to hold GCC and its counselors harmless in any and all matters associated with the biblical advice you receive.

Confidentiality: Confidentiality is an important aspect of the counseling process, and we will carefully guard the information you entrust to us. However, there are several situations in which it may be necessary for us to share certain information with others:
1. When a counselor is uncertain of how to address a particular problem and needs to seek advice from another biblical counselor, pastor, or elder in his church.
2. When a counselee attends another church, and it is necessary to talk with his or her pastor or elders.
3. When there is an indication that someone may be harmed unless we otherwise intervene. This includes issues regarding physical abuse, suicide attempts and illegal activity.
4. When a person persistently refuses to renounce a particular sin, and it becomes necessary to seek assistance from others in the church to encourage repentance and reconciliation (Proverbs 15:22, 24:11; Matthew 18:15-20).
5. When training others to be effective counselors, and they need to observe the counseling process.
Please be assured that in our counseling we strongly prefer not to disclose personal information to others and will make every effort to help you find ways to resolve a problem as privately as possible. If these confidentiality guidelines are acceptable to you, please sign below.

Resolution of Conflict: On rare occasions if a conflict arises between a counselor and counselee, an agreement is hereby made to settle the conflict with mediation within the church and according to principles of Scripture. If this and all other guidelines above are acceptable to you, please sign below.

If this and all other guidelines above have been fully read and are acceptable to you, please check the below boxes in representation of your signature

Signed & Agreed

Name of Signed Above

Parent (if with minor child)

Dated

Submit

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