PDI Form for G. Gabriel Powell

Completed: 0%

Note: If a question on the form does not apply, please leave it blank.

Name

Address

Address Line 2

City

State/Province

Zip/Postal Code

Primary Phone

Secondary Phone

Email * This will allow you to receive a copy of the completed form.

Referred By

Birth Date (MM/DD/YYYY)

Gender: Male Female

Completed Education

Marital Status

Employer

Position

Years at Employer

Is English your first language?
Yes No If not, what is?

Completed: 12%

What is the main problem, as you see it? What brings you here? - required

What have you done about the problem? - required

What are your expectations in coming for counseling? - required

Is there any other information that we should know?

Does anyone from your church plan to accompany you to counseling? Yes No

If Yes, please indicate his/her name(s), and the nature of your relationship with them.

Completed: 24%

Spouse

Birth Date (MM/DD/YYYY)

Occupation

Years at Employer

Primary Phone

Secondary Phone

Email

Date of Marriage (MM/DD/YYYY)

How long did you date?

Circumstances of meeting and dating (brief)

Is your spouse willing to come for counseling? Yes No If not, please explain

Is your spouse in favor of your coming? Yes No If not, please explain

Have either of you been previously married? Yes No If so, to whom?

Have you ever been separated? Yes No

Have you ever filed for divorce? Yes No

If there have been multiple marriages, briefly explain time frames, children involved, and reasons.

Information About Children:

Additional Children (separate information with commas, one row per child.)

Describe your relationship to your parents

Number of Siblings

Birth order of all siblings

Did you live with anyone other than your parents growing up?

Are your parents living? Do they live locally?

Completed: 36%

Describe your health

Do you have any chronic conditions (pain, headaches, insomnia, etc.)? Yes No If so, what:

List important illnesses and injuries or handicaps

Approximate Date of last exam:

What was the report?

Physician's name and address

Current medication(s) and dosage

Have you ceased taking any drugs recently? Which ones, why, and when?

Have you ever used drugs for anything other than medical purposes? Yes No If so, explain

Have you ever been arrested? Yes No If so, why, when, and was there a resulting sentence?

Do you drink alcoholic beverages? Yes No If so, how frequently and how much

Do you drink coffee? Yes No How much?

Other caffeine products consumed

How much?

Do you smoke? Yes No What: Frequency:

If you have ever had interpersonal problems on the job, please describe them

Have you ever had a severe emotional upset? Yes No If yes, please explain

Have you ever seen a psychiatrist or counselor? Yes No If yes, how was it helpful? 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? Yes No

Completed: 48%

Denominational Preference

Church attending I am a member

Location

Pastor's Name

Pastor's Phone Number

Do we have permission to contact your pastor? Yes No If not, please explain why: * Permission to contact your pastor includes sharing information on this PDI.

Church attendance per month:

Do you believe in God?     Yes    No
Do you pray?     Yes    No
Would you say that you are a Christian?     Yes    No    Or interested in becoming a Christian:     Yes    No    Have you ever been baptized?     Yes    No

How often do you read the Bible?

Explain any recent changes in your spiritual life

Completed: 60%

Have you had any menstrual difficulties: Yes No

If you experience tension, tendency to cry, other symptoms prior to your mestrual cycle, please explain

Have you ever had an unplanned pregnancy? Yes No

Have you ever had an abortion? Yes No

If you had an abortion, did you suffer any medical side-effects that would be helpful for your counselor to know?

Completed: 72%

Please select areas you are struggling with.

Completed: 84%

Before filling out the Personal Data Inventory information, it is important that you read and understand the following information regarding biblical counseling with me.

I am not certified by the State of California, but I am certified with the Association of Certified Biblical Counselors (a Biblically sound organization).

There are, however, several conditions upon which counseling cases will be initiated, and possibly terminated. They are as follows:

Counseling of members of my local church always takes precedent over all outside counseling.
Since I am closely tied with two counseling training institutions, I may seek your permission to have a trainee in the counseling room with us for observation. I will respect your decision if you decline, but it is valuable experience for the trainee and a way you can serve the body of Christ.
All counseling will be conducted in accordance with my understanding of the Scriptures. Your counseling will be biblical in that the Scriptures are the final authority in all cases. If you are not sure that you will be interested in biblically-based counseling, you have the option of attending one or two sessions to discover what biblical counseling is like. If you are unwilling to use the Bible as the final authority in counseling or unwilling to do the homework assigned, sessions will be terminated.
Please encourage your pastor from your local church or one of those in its leadership to accompany you in counseling sessions. I fully recognize and respect the authority and the discipline of your church. And, in addition, this makes transfer back to the pastoral care of your church much easier to effect. If you are not attending a church, I will expect you to attend a Bible preaching and believing church weekly. If you so desire, I will be glad to make a recommendation.
Information disclosed in counseling sessions will be held confidential only as I believe the Bible or the State requires. Absolute confidentiality is not scriptural. In certain circumstances the Bible requires that facts be disclosed to selected others (Matt. 18:15ff). If your church leadership should inquire, we will disclose to them only that information which we believe is necessary for them to effectively and biblically fulfill their responsibility to shepherd you.
At any time during the counseling, for reasons sufficient to myself—as also you—shall have the option of terminating counseling.
All counseling is done free of charge as a ministry to you. However, part of the weekly homework assignments may require purchasing materials that correspond to the counseling.
It should be understood that biblical counseling consists of the giving of scriptural advice and the practical application of the same to each individual. Yet, you are held fully responsible for how you implement that advice.

I am confident that the Bible has all of the information necessary for life and godliness (2 Pet. 1:3). There are no problems between persons that the Bible fails to address either in general or specific principles. I am not infallible, nor do I pretend to know all there is to know about biblical teaching and its applications to life, but I am well equipped and competent to help you change. I will make a point to differentiate between God's commands and my suggestions. I will also honestly tell you if I am stymied and will seek help.

If a conflict should arise between you and me, we must agree to resolve the dispute outside the secular court system. Conciliation will be sought under submission to and direction of certified Christian Conciliator.

Electronic Signature

I, (electronic signature required), have carefully read the conditions for counseling set forth on this page and agree to enter into counseling in accordance with them.

I am filling out this form on behalf of the counselee:

My Name

Relationship

Completed: 100%

Thank you for taking the time to fill out this form! Your complete and honest answers will aid the counseling process and allow me to better understand you and your situation.

I would encourage you, if you have not already, to go back and review your answers. Once you click "Finish" I will receive an email with your answers. If you filled in your email address under the Personal section, you will receive a copy of your PDI.

I will contact you in the next few days to set up a meeting time and location that is convenient for both of us. If you have any questions or concerns, please do not hesitate to contact me by email or (661) 714-2574.

Click "Finish" to submit your Personal Data Inventory.