Personal Data Inventory 

(Please completely fill out this form and make it available to your counselor before your first counseling session.) 
Name: _____________________________________________________________________________________
Address: _____________________________________________________________________________________
       (Street) 				(City) 				(State)		 (Zip) 
Sex: _______     Age: _______    Date of Birth: _______________    Phone:  ( _______ )  _________ - ____________
Email: ______________________________________________________________________________________     
Occupation: ________________________________    Education/Training: _________________________________
Marital Status: Single ____ Dating ____ Engaged ____ Married ____ Separated ____ Divorced ____ Widowed ____

Spiritual Heart Diagnosis 
When you visit a doctor, they take your blood pressure, temperature, etc. We diagnose levels of faith, hope, and love. The following questions will help us take your spiritual temperature. 
1)	List the things that most often motivate hope (just looking forward to them puts you in a good mood even before they actually happen).

2)	Which of the following best describes you?
A.	I trust my instincts.  If I strongly feel that something would make me happy, but the Bible forbids it, I will generally go with my own instincts and belief rather than conform to what the Bible says.
B.	I believe everything in the Bible is true and is the Word of God, and so my goal in life (even though I often fail) is to always follow whatever the Bible says no matter how I feel. 
C.	Not sure

3)	Which best describes you?
A.	I have very little interest in what the Bible says.
B.	I'm content to have an average understanding of the Bible. 
C.	I am working hard to develop as thorough an understanding of the Bible as I possibly can.

4)	Last week, outside of church, I read my Bible ____ times. 
On average I read the Bible about _____ times per week. 

5)	Which of the following best describes your life?
•	Following Jesus Christ and the commandments of God is of little interest to me.
•	Following Jesus Christ and the commandments of God is one of many important things in my life.
•	Following Jesus Christ and the commandments of God is by far the most important pursuit of my life.

6)	Which best describes your life?
•	A life of obedience (and whenever I fail, repentance).
•	A life of mostly obedience but with a few areas of disobedience that I'm not really ready to give up.
•	God's commands have little impact on how I live.

7)	Which of the following have a significant presence in your life?
•	Worry 
•	Fear
•	Distress over what others think
•	Anxiety 

8)	Rate yourself from 1 to 10 on each of the following (1 – completely lacking in your life, 10 – your life looks like what the Bible calls for in this area)
_____ patience with people
_____ kindness
_____ being happy when good things happen to others even when they don’t happen to you
_____ humble speech (no effort to cause people to be impressed with you)
_____ humility (more care for others than for self)
_____ politeness, courtesy, making others feel comfortable 
_____ selflessness (as opposed to selfishness)
 
9)	If someone looked at  your credit card statement (how you spend your money), and how you spend your free time, how you spend your energy, and could observe where your thoughts go, that person would probably conclude that the most important thing(s) in your life is(are):

10)	When you are feeling down, what kinds of things are such a delight to you that they can bring you back to a good mood?

11)	What are the deepest cravings of your soul? (What is it that it seems like would bring you the most happiness?)

Please mark the answer that best fits your beliefs.

12)	God is…
A.	A personal being with emotions, desires, etc.
B.	An impersonal force
C.	Not sure

13)	Regarding Exclusivity...
A.	It doesn’t matter much which God a person worships, as long as he/she is sincere.
B.	All religions worship the same God.
C.	Only the God of the Bible is the true God. All others are false gods.
D.	Not sure

14)	Regarding God’s Control...
A.	God is in full control of all things (but never causes evil).
B.	God sometimes intervenes in human affairs, other times He does not.
C.	God does not intervene in human affairs.
D.	Not sure.

15)	Regarding Jesus...
A.	Jesus Christ is the one, true, Almighty, eternal, Creator God.
B.	Jesus was a great Prophet, but not God.
C.	Not sure.

16)	Regarding Jesus’ death and resurrection...
A.	The accounts of Jesus rising from the dead may or may not represent actual history. The important thing is not whether it actually happened physically, but rather the spiritual meaning.
B.	Jesus died on the cross to take the punishment I deserved for my sin, and on the third day He rose from the dead physically, bodily, literally, and then ascended into heaven where He is currently exalted at the right hand of God the Father
C.	Not sure

17)	A person can be forgiven of sins and go to heaven by...
A.	Living a good life (acts of love, prayer, Bible reading, church attendance, etc.).
B.	Believing the truth in the Bible and trusting Jesus Christ enough to follow Him as a devoted (not just casual) follower.
C.	Praying a prayer Inviting Jesus into one’s heart.
D.	Not sure.

18)	In order to be a Christian...
A.	One must repent of sin
B.	Repentance is ideal, but not required
C.	Not sure

Life Experience Information

State in your own words the nature of the main problem(s) that bring you for counseling:
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When did your problems begin?  Please specify a date if possible.
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Please describe any significant events occurring at that time.
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Have you or others noticed any changes in your personality (anger, mood swings, withdrawal) thinking and memory, or work habits? □ Yes / □ No   If “yes,” please describe: ____________________________________________________________________________________________
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What do you feel your spouse’s chief complaints about you are? (Fill out only if you are seeking marriage counseling).
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What have you done to try to resolve your problems(s)?
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Are you regularly attending church? If so, which church? And why are you not seeking counsel from your pastor? 
If you do not attend church, why not?
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What would you like to see accomplished by this counseling?
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Mark each item that describes you at this time:
•	Unsure of whether I would go to heaven if I died today
•	Nothing is more important to me than following Jesus
•	I believe everything in the Bible
•	I trust Jesus Christ enough to follow His way even when it doesn’t seem best to me
•	I feel more joy than sorrow
•	I feel more sorrow than joy
•	When I feel discouraged about the future, it helps when I think about ______________________________

•	I think God is displeased with me because: ____________________________________________________

•	I think God is pleased with me because:_______________________________________________________
Is there any other information we should know?
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Please rate how much these are areas of struggle and/or conflict in your life. 
(0) = not a struggle (1) occasional struggle (2) regular struggle (3) consuming struggle 

____ Anger 
____ Anxiety 
____ Apathy
____ Bitterness 
____ Change 
____ Children 
____Communication 
____Covetousness 
____ Day dreaming/thought life 
____ Death 
____Deception 
____Decision making 
____ Depression 
____ Drug Use 
____ Drunkenness 
____ Envy/Jealousy 
____ Fear 
____ Finances 
____ Gluttony 
____ Guilt 
____ Health 
____ Homosexuality 
____ Impatience 
____ Impotence 
____ Impulsiveness 
____ In-laws 
____ Loneliness 
____ Lust 
____ Manipulation 
____ Memory 
____ Moodiness 
____ Perfectionism 
____ Pornography 
____ Pride 
____ Rebellion 
____ Relationships 
____ Sex 
____ Sleep 
____ Spouse abuse 
____ Strife 
____ Vices Specify:__________) 
____ Vomit after eating ____Other areas of significant struggle or conflict: __________

Counseling Consent 
Our Goal:  The purpose of biblical counseling is to help you meet the challenges of life in a way that will please and honor the Lord Jesus Christ.  We offer counseling free of charge, as a ministry of Agape Bible Church.  Counselees may donate to the ministry (which will go toward the training of more counselors), but this is not expected or required as a condition for the counseling.  
Biblical Basis:  Agape counseling is strictly religious in nature, conducted under the authority and leadership of the church.  We believe that God, through His revelation in the Old and New Testaments of the Bible, has provided His people with thorough guidance and instruction for faith and life (2Tim 3:16-17; 2Peter 1:3-4).  Our counseling is based solely on scriptural principles.  We reject the teachings and methods of modern psychology or psychiatry, whether expressly secular of an attempted integration with biblical principles.  Agape counselors are not professional, and under Colorado law no such licensing is required.  They do not follow the methods of psychotherapy, and our policy is to not make referrals to psychologists or psychiatrists.
Initials_______________________
Other Professional Advice:  If you have significant medical, legal, financial, or other technical questions, you should seek advice from a competent independent professional.  Our counselors will cooperate with such advisors and help you to consider their counsel in the light of scriptural principles.
	More specifically, we urge our counselees to properly care for their physical bodies and to seek proper medical treatment for all physiological problems.  Our counselors will assist you in responding to such problems in a godly manner but our counsel is not intended to replace the services of a qualified physician where organic problems are present or where medication has been prescribed.
Confidentiality:  Confidentiality is an important aspect of the counseling process.  We will carefully guard the information you entrust to us to the fullest extent possible.  There are times, however, when it may be necessary for us to share certain information with others.  Examples include, but are not limited to, the following:
1.	Where a person refuses to renounce a particular sin, it may become necessary to seek the assistance of others in the church to encourage repentance and reconciliation (Prov. 15:22, 24:11; Matt. 18:15-20).  In such cases, we will reveal only such information as is necessary for such purposes, and only to those biblically required to be involved.  Where a counselee is a member of another church, it will most likely be necessary to contact the pastor and /or elder(s) of such church.
Initials_______________________
2.	Where a counselor is uncertain as to how to address a particular counseling issue, he may seek advice from a pastor or another counselor.
3.	Where a counselee threatens harm to another person, it may be necessary to intervene in order to prevent such harm.
4.	The law may require a counselor to reveal spousal or child abuse, or some other crime, to the appropriate authorities.
5.	Observers may sit in on counseling sessions, either to assist in the process or for training purposes.
Conflict Resolution – Arbitration:  On rare occasions, a conflict may develop between a counselor and counselee.  1 Corinthians 6:1-8 forbids Christians from bringing lawsuits against one another in secular courts of law.  In order to ensure that such conflicts are resolved in a biblical faithfully manner, we require all of our counselees to agree that any dispute with a counselor of with this church will be settled by mediation and, if necessary, legally binding arbitration conducted in accordance with the Rules of Procedure of the Institute for Christian Conciliation.  (A copy is available on request.)  The arbiters will be the elders of Agape Bible Church.  If one or more elders of the church is a party to the dispute, then three arbiters will be selected form the deacons, with each party to the dispute choosing one arbiter, and the two arbiters then selecting the third.  It is expressly understood that, by consenting in advance to such arbitration, the counselee is waiving his right to a trial in the civil courts.
Initials_______________________
Having clarified the principles and policies of our counseling ministry, we welcome the opportunity to minister to you in the name of Christ and to be used by Him as He helps you grow in spiritual maturity and prepares you for usefulness in His body.  If you have any questions about these guidelines, please speak with your counselor.  Your signature below indicates your informed consent to these guidelines.
Signed______________________________________________  

Dated_________________________