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Menu
VISIT
ACT
ACT
7 Steps
Prayer
Counseling
Family Worship
Sunday
About
Who We Are
What we Believe
Our Pastors
Directions and Times
What to Expect
Kids and Youth
CONNECT
Giving
Youth
Welcome
Kids page
Teens page
Tools for parents
WATCH
Personal Data Inventory
Please complete the form below
Name
*
First Name
Last Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Best Contact Phone Number
*
(###)
###
####
Email
*
Sex
*
Male
Female
I choose not to answer
Date of Birth
*
Employment
*
Please include your position and how long you have been employed.
Have you ever been arrested?
*
Yes
No
Have you ever been hospitalized?
*
Yes
No
FAMILY PROFILE
Give a description of your family
*
Please list both the strengths and the weaknesses of your family. Also list how many siblings you have.
Length of Dating
*
Length of Engagement
*
Previous Marriages?
*
Yes
No
Age at Marriage - Husband & Wife
*
Religion
*
Education
*
Background of Family Origin
*
Click all that apply to your family
History of divorce
Foster Care
Adopted
United Family
Close Family
Detached or Divided Family
Antagonistic/Violent Family
High Income Family
Medium Income Family
Low Income Family
Big Family (More than 3 siblings)
MEDICAL PROFILE
Describe your overall Health
*
Checkbox
*
Check all that apply
Drink Alcoholic Beverages
Used recreational drugs
Use tobacco products
Exercise Regularly
Trouble sleeping
Feel Healthy
EMOTIONAL PROFILE
Have you ever had a severe emotional upset?
*
Yes
No
Check all that applies to you
*
Check all that apply
Had Psychotherapy
Been to Counseling
Had a major loss
Recently suffered the loss of someone close to you
Feel people are watching you
Colors seem too bright
Colors seem too dull
Difficulty distinguishing faces
Unable to judge distance
Had hallucinations
Afraid of being in a car
Exceptionally good hearing
Live an exceptionally stressful life
RELIGIOUS PROFILE
Denominational Preference:
*
What are your religious beliefs?
*
Check all that apply
*
Been baptized
Attended church as a child
Believe in God
Pray everyday
Been saved
Read the Bible
Attend Church
Member of a church
Do regular devotions
Involved in ministry
Ever Fasted
Believe Satan exists
Dabbled with the occult
Recent changes in your Spiritual life
*
Do you have doubts or problems? Major life changes that affects your belief system.
BRIEFLY ANSWER THE FOLLOWING QUESTIONS
As you see yourself, what kind of person are you?
*
Describe yourself.
Describe your relationship with your parents and siblings.
*
Check any of the following words which best describe you:
*
Godly
Angry
Ambitious
Cruel
Often-blue
Nervous
Good-Natured
Calm
Self-Conscious
Leader
Lonely
Well-groomed
Ethical
Proud
Unreasonable
Uneducated
Excitable
Hardworking
Extrovert
Serious
Sensitive
Quiet
Failure
Self-disciplined
Hypocritical
Embarrassing
Abusive
Impulsive
Self-Confident
Impatient
Likable
Easy-going
Humorous
Success
Selfish
Strict
Active
Irresponsible
Moody
Persistent
Introvert
Imaginative
Shy
Sloppy
Submissive
Whiner
How much media and video games do you watch each day?
*
Total time on phone, or devices for entertainment
1 hour
2 hours
3 hours
4 or more hours
List your favorite TV programs, Movies, Music, and Entertainers.
*
What if anything do you fear?
*
What do you do when you get angry?
*
Explode
Cry
Withdraw
Argue
CHILDHOOD PROFILE
List three words that describe what kind of home you were raised in:
*
Where did you grow up?
*
Urban Area
Suburban Area
Small town
Rural
Farm
What was your happiest and unhappiest memory as a child?
*
Did you experience a major trauma when you were a child? Explain:
*
PARENTAL PROFILE
Choose three words that best describe your father:
*
Choose three words that best describe your mother:
*
What kind of homes where your dad and mom raised in?
*
MARRIAGE PROFILE
Check all that you are concerned about when it comes to marriage:
*
Finances
Getting along
Parenting
Abuse
Sex
Expectations
Divorce
In-Laws
Staying in love
Change in Lifestyle
Communication Issues
Fighting
Ignoring Boundaries
Jealousy
Choose three words about your fiancé that describe them:
*
What are you hoping to learn during counseling?
*
Is there any other information you think the counselor would know this is the place as well.
Thank you! Pastor Rob will contact you soon to set up your first appointment.
