Personal Data Inventory Form

Personal Data Inventory
Please answer the following questions about yourself.
Date
Name*
First Last
How Did You Hear About Us?
- Friend
- Facebook/Twitter
- Church/Bible Study
- Google Search
- Other
If you heard about us through a friend, please tell us their name
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Cell Phone
Email
Age
Please enter a value between 0 and 99.
Gender
- Male
- Female
Marital Status
- Single
- Married
- Separated
- Divorced
- Widowed
Occupation
Where do you work?
Education
List Education

Previous Marriages and Family Information
Please give any information about any previous marriages and past/present family.
Please list any previous marriage(s) and include the dates for those marriages.
Do you have children?
- Yes
- No
Are any of your children from a previous marriage?
- Yes
- No

Basic Problem Identification
What is the problem that brings you here?
What have you done about it?
What are you seeking (and expecting) from biblical counseling?
Is there any other information that you think we should know?

Religious Background
Are you a member of a church?
- Yes
- No
What Church?
What is your relationship to Jesus Christ?
Describe any recent changes in your spiritual life:

Health Information
Rate your health
- Excellent
- Good
- Average
- Declining
- Other
List any relevant present or past illnesses, injuries, or handicaps
Do the above limit you in any way?
- Yes
- No
Approximately how many hours of sleep do you get each night?
When do you usually go to sleep?
When do you usually get out of bed?
Date of last medical exam
Medical exam report
NOTE: Before you submit this Personal Data Information Form, please read the "Statement of Understanding" on the next page and submit your signature in order to complete your registration.

STATEMENT OF UNDERSTANDING

I understand that anything I tell my lawyer, clergyman, Ph.D. level counselor, or doctor as part of our professional relationship is legally “privileged” communication. That is, it is legally protected from being disclosed to anyone else, unless I give permission that the communication be disclosed to someone else, and that with very limited exception, my lawyer, clergyman, Ph.D. level counselor, or doctor cannot reveal anything they learn as part of their professional relationship with me unless I give permission that the information may be disclosed.

On the other hand, I also understand that what I tell anyone other than my lawyer, clergyman, Ph.D. level counselor, or doctor, even in a helping or lay ministry setting such as this offered by Biblical Counseling of AZ is not legally “privileged” communication, it is not legally protected from being disclosed to anyone else.

I request to receive services from Biblical Counseling of AZ and understand it is a Lay Ministry. I also understand and agree, as a condition of receiving these services, that the individual I will be meeting with is under the supervision of their own pastor and:
- is not a lawyer, clergyman, Ph.D. level counselor, or doctor;
- is not someone with whom communication is legally privileged from disclosure;
- is committed to providing biblically based guidance to me, but cannot provide me with professional legal, mental, or medical services.
I fully understand and agree that my communication is not privileged and is not protected from being revealed to others. That is, what I disclose to the counselor may later be forced to be disclosed to a Judge, to a law enforcement officer, or to an opposing party or to their attorney, I release Biblical Counseling of AZ from any liability for such disclosure.

I also understand that Biblical Counseling of AZ encourages and advises me to consult with my lawyer, Ph.D. level counselor, clergyman or doctor for any professional services or counsel needed of which I intend to be legally privileged from disclosure.

GOAL OF BIBLICAL COUNSELING OF ARIZONA (BCA)

Our specific goal in counseling at BCA is to walk beside you for a period of time, reveal and/or remind you of the God of scripture and reconnect you with members of your body under your pastoral care. Total ministry of a church includes sound preaching, teaching and fellowship that biblically supports you with accountability for daily, weekly, monthly, yearly walking with Christ. If you are not attending church or if your church is not structured to provide the kind of support received at Biblical Counseling of AZ, we will encourage you to attend a Bible-believing church in the area on a weekly basis.

I understand there will be charges for services rendered. All extra materials needed I will be responsible to pay including books, pamphlets, and other materials my counselor may offer. This is not considered a tax deductible donation.

By signing below, I acknowledge: that I sign this Statement of Understanding & Goal of BCA voluntarily, free from deception, undue influence, coercion, or duress of any kind, that I have given careful and mature thought to signing this statement; that I have carefully read each provision of this statement; that I fully and completely understand each provision of the statement; and that I have the right to consult with legal counsel if I choose to prior to signing this statement.
Signature*

Is this Counseling for a Minor?*
- Yes
- No
I am the parent or legal guardian of the minor child whose name appears below. I have custody of my child and am under no court order which would prevent me from seeking counsel on my child’s behalf.

I have read and agree to be bound by the terms in the “Biblical Counseling of AZ services” ministry form attached hereto and incorporated by reference herein. I understand that all counseling provided my child will be based on biblical principles which may or may not be in accordance with modern psychological standards. By requesting counsel from Biblical Counseling of AZ, I intend to exercise my fundamental right to instruct my child in the principles of the Christian faith.

By affixing my signature below, I give Biblical Counseling of AZ permission to counsel my child.
Minor's Name*
First Last
Minor's Date of Birth*
Signature*
Name
This field is for validation purposes and should be left unchanged.

Step 1 of 7

Personal Data Inventory

Education

Previous Marriages and Family Information

Basic Problem Identification

Religious Background

Health Information

NOTE: Before you submit this Personal Data Information Form, please read the "Statement of Understanding" on the next page and submit your signature in order to complete your registration.

STATEMENT OF UNDERSTANDING

GOAL OF BIBLICAL COUNSELING OF ARIZONA (BCA)