Personal Data Inventory

Please fill out the personal data inventory form

The Personal Data Inventory, or PDI, is a very important part of the counseling process. It gives us the background information we need in order to best determine a course of action in your counseling. Please do your best to provide complete and honest answers in the PDI so we have the best information available.

Required fields are marked with a red asterisk.

This is a long form and could take some time to fill out. If you need to come back to it later, please click the “save and continue” button at the bottom of the form and follow the instructions.

If you would rather fill out a hard copy of the PDI, you can download it here. Please fill it out and email it to biblicalcounselingsa@gmail.com.

PDI

Personal Data Inventory for biblical counseling (intake form).

"*" indicates required fields

Step 1 of 5

Indentification Information

Name*

First Last

Phone*

Email*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employment

Occupation*

Business Phone*

Personal Information

Sex*

Male

Female

Birth Date*

Age*

Please enter a number from 5 to 99.

Age*

Please enter a number from 5 to 99.

Height*

Weight*

Please enter a number from 10 to 500.

Marital Status*

Referral

Referred here by

First Last

Their address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Education

Last year completed*

Grade*

Other Training (list type and years)

Health Information

Rate your health (select one)*

List all important present or past illness or injuries or handicaps

Date of last physical examination

Results of last exam

Physician's address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Have you used drugs for other than medical purposes?*

Yes

Which ones?

Have you ever had a severe emotional upset?*

Yes

Explain

Marriage and Family Information

Name of spouse

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Occupation

Business Phone

Spouse's Age

Education (in years)

Religion

Is your spouse willing to come to counseling?

Yes

Uncertain

Have you ever been separated?

Yes

When? From

Have either of you ever filed for divorce?

Yes

When?

Date of marriage?

Length of steady dating with spouse

Length of engagement

Give brief information about any previous marriages for either of you

Information About Children

List

Name

Date of Birth

Sex

Living? (Y)/N

Education (in years)

Marital Status

Previous marriage? (Y/N)

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

Older brothers?

Older sisters?

Younger brothers?

Younger sisters?

What, from your perspective, is the primary problem/issue that brings you here for counseling?*

What have you done about it?*

What do you hope we can do about it?*

Anything else you might want to add?*

Consent to Biblical Counseling/Discipleship (please read to the end)*

I agree with all stipulations described herein

Regular attendance at counseling sessions is vital as is completion of assigned homework.

On the date of agreement, it is agreed that, should David and/or Jocelyn Whalen (counselor(s)) agree to provide biblical counseling services to (counselee), the following terms and conditions shall apply:

Biblical Counseling: This is a ministry of the Gospel of Jesus Christ and is part of Counselor's practice of religion. Counselee has indicated that Counselee is a Christian and is voluntarily seeking religious guidance (biblical counseling) from Counselor, as a part of Counselee's practice of religion. The goal of biblical counseling is to help Christians become more like Jesus Christ in attitude, thought, and action.

Counselor's goal in providing counseling is to help Counselee live life in a God-honoring way. This includes, but is not limited to, providing biblical counsel to assist in meeting the challenges of life, shedding the sin that so easily entangles, learning to develop, cultivate, and live in relationships that please God, giving thanks to God in all circumstances, living in a community of other believers through participation in a local church, and learning to rely on the Holy Spirit for direction as Counselee seeks to know God through the Bible. Although the biblical advice Counselor provides is intended to be practical, it is entirely Counselee's decision how to (and whether to) implement that advice. Counselor wants to help Counselee love God and love others through this process.

Biblical Basis: Counselor believes that the Bible provides sufficient guidance and instruction for faith and life. Therefore, counseling is based on biblical principles rather than those of secular psychology or psychiatry. Counselor is not licensed or certified as a psychotherapist, psychologist, psychiatrist, mental health professional, marriage and family therapist, or social worker, and is not acting in such capacities.
If Counselee is unwilling to use the Bible as the final authority in counseling or is unwilling to do the homework assigned, Counselee should not proceed with this counseling.

Professional Advice: Counselor is not providing legal, tax, financial, medical, or other technical or professional advice and Counselor undertakes no duty to recognize or opine when such advice is actually needed, and the parties further agree that no fiduciary or professional client relationship is being created between Counselor and Counselee as a result of this relationship. While the counselee may provide renumeration for the ministerial services provided pursuant to this agreement, such renumeration does not change this relationship from a religious to a "professional" or "fiduciary" relationship.

Confidentiality: Confidentiality is conditional. Although confidentiality is often one aspect of the counseling process and Counselor intends to guard the information received from Counselee, there are a number of situations when it may be necessary or prudent (as determined in Counselor's sole discretion) for Counselor to share information with others. Counselee agrees that Counselor may share information in at least the following circumstances:
When Counselor is uncertain how to address a problem and needs to seek the advice from a pastor, supervising counselor, or educator. (Proverbs 11:14; 24:6).

When there is concern that someone is being or may be harmed unless other persons or protective services intervene (Romans 13:1-7).

When Counselee expresses clear and specific suicidal intent, Counselor may take reasonable measures for the safety of Counselee. Reasonable measures may include notifying police if the Counselee will not cooperate to involve him or herself in a watch-care program or facility.

If Counselor has reasonable cause to believe that an adult is in need of protective services, Counselor may take reasonable measures to prevent harm. Reasonable measures may include directly advising the potential victim of a threat or intent and/or informing the appropriate protective and/or law enforcement agencies.

If there is a claim of, the observance of, or clear reasonable cause to suspect the physical or sexual abuse of a child with whom Counselor comes into contact or who is associated with someone to whom Counselor is in contact with, reasonable measures may be taken to ensure the child's protection and/or to fulfill the legal mandate to report such harm to the appropriate governmental protection agencies.

When Counselor becomes aware of any other criminal activity Counselee is engaged in and Counselee refuses to bring to the appropriate biblical and/or legal authorities.

When counseling someone who is under familial authority (e.g. wife to husband, child to parent) and if deemed safe by Counselor, Counselor may encourage Counselee to inform Counselee's familial authority of critical issues and/or Counselor may inform the familial authority (Ephesians 5:22-6:4).

When a person refuses to renounce a particular sin and/or refuses to confess it to those impacted, Counselor may in Counselor's discretion, seek the assistance of a trusted member or leader of any involved church to encourage repentance and/or reconciliation (Proverbs 15:22, 24:11; Matthew 18:15 - 20).

When Counselor deems it appropriate or necessary to discuss information with a training observer or an assisting advocate who is involved or observing counseling.
When the counselor needs to make periodic reports to the church leadership in authority over counseling ministry.

When Counselee makes a complaint against Counselor, an ACBC counselor, or a counseling center or other related organization, it is agreed that the dispute will be handled biblically, outside the court, and may involve sharing information with an assisting local Church Shepherd and/or the appropriate person(s) within the ACBC organization for complaint resolution purposes.

Please be assured that counselors strongly prefer not to disclose your personal information to others (if not needed), and they will make every effort to help you find ways to resolve a problem as privately as possible.

Liability: It is intended that the Holy Scriptures (the Bible) shall be the authority governing the counseling process, and that God's glory is the ultimate goal. However, failure of Counselor to interpret or apply the Bible in any particular way shall not subject the Counselor to liability or give rise to complaint by anyone. There shall be no legal or other liability that attaches to Counselor or any related institution or person for any advice, methods, conduct, or any act or omission related in any way to the service that is provided, and Counselee acknowledges that Counselee is voluntarily seeking this counsel (free from coercion, duress, or pressure) with a full understanding of the nature, purpose, and effect of this agreement.

Termination: At any time and for any reason, Counselor or Counselee may terminate counseling. However, termination will not preclude Counselor from making the disclosures set forth above if deemed appropriate by Counselor, or if compelled by other legal means. Counselor is not required to keep records, but if records are made, Counselor may destroy any such records without incurring liability.

Resolution of Conflicts: On rare occasions, a conflict may develop between a Counselor and a Counselee. In order to make sure that any such conflicts will be resolved in a biblically faithful manner (the Bible prohibits lawsuits in court among believers; 1 Cor. 6:1-8), the parties agree that if a conflict arises, the conflict will be resolved according to the ACBC dispute resolution proceedings, which are then operative. That conflict resolution policy may be found at https://biblicalcounseling.com/acbc-member-complaint-case-policy/.

BY SIGNING THIS DOCUMENT, YOU ARE IRREVOCABLY WAIVING ANY RIGHT THAT YOU MIGHT HAVE TO A TRIAL BY JURY OR JUDGE IN A JUDICIAL PROCEEDING.

If any provision of this agreement shall be held invalid, illegal, or unenforceable, only that provision shall be stricken and the remainder of the agreement shall be in no way affected.

By checking the box above, the parties agree to the terms and conditions set forth in this document and acknowledge that Counselor would not enter into this counseling relationship without each term set forth above.

Upon checking box that says, "I agree with all stipulations described herein," you agree to all of the above terms and conditions.

Personal Data Inventory

PDI

Indentification Information

Employment

Personal Information

Referral

Education

Health Information

Religious Information

Legal and Counseling Information

Marriage and Family Information

Information About Children