STEVEN HOCKER
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CompassPoint Biblical Counseling
PERSONAL DATA INVENTORY
Please complete the following 4-part form, and click submit when completed. It should take about 10-minutes to complete.
Part 1 - Personal Information
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Indicates required field
Name
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Date of Birth
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Street
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City
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State
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Zip Code
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Email
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Phone
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GENDER
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Male
Female
hobbies
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Marital Status
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Single
Engaged
Married
Separated
Divorced
Remarried
Widowed
Education
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Elementary
High School
GED
Undergraduate Degree
Graduate Degree
spouse's NAME
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spouse's PHONE
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AGE
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spouse's OCCUPATION
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spouse's Religion
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# Years Married
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Are You Presently Living with Your Spouse?
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Yes
No
Is Your Spouse Aware You Want Counsel?
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Yes
No
Maybe
Is Your Spouse Willing to Come with You?
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Yes
No
Maybe
PLEASE LIST ANY CHILDREN YOU HAVE
Name
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Gender
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Male
Female
age
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name
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gender
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Male
Female
age
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name
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gender
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Male
Female
age
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name
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gender
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Male
Female
age
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Part 2 - Health Information
Date of Last medical Examination
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Outcome of Examination
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Height
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Weight
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Are you willing to sign a release of information so we may request reports from your doctors?
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Yes
No
Rate Your Health
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Very Good
Good
Average
Declining
Poor
Are you presently taking medication?
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Yes
No
Please list medications
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please list past illnesses or injuries:
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How many hours of sleep do you get?
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More than 9 hours
7-8 hours
5-6 hours
3-4 hours
Less than 3 hours
Do you use drugs or alcohol?
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Yes
No
Please List Drugs or Alcohol
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Doctor name and contact information:
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HAVE YOU EVER BEEN TO COUNSELING BEFORE?
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Yes
No
WHAT WAS THE OUTCOME OF YOUR COUNSEL?
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COUNSELOR NAME AND PHONE NUMBER
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HAVE YOU EVER HAD SEVERE EMOTIONAL UPSET?
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Yes
No
PLEASE LIST ANY FEARS YOU HAVE:
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please list any concerns you have:
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Select the words the best describe how you recently feel
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Active
Ambitious
Hardworking
Excitable
Shy
Leader
Lonely
Impatient
Fearful
Quiet
Self-Conscious
Self-Confident
Calm
Introvert
Inflexible
Bitter
Persistent
Moody
Serious
Extrovert
Submissive
Angry
Anxious
Often Sad
Easy Going
Likeable
Sensitive
Part 3 - Religious Information
Do you believe in God?
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Yes
No
Maybe
Denominational Preference
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Have you been baptized?
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Yes
No
How often do you read the Bible?
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Never
Occasionally
Weekly
Daily
Do you pray?
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Yes
No
Maybe
Church Name
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Monthly Attendance
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Less than 2 times
3-4 times
5-8 times
More than 9 times
Do you read the bible or pray as a family?
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Yes
No
Occasionally
Do you believe you are saved?
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Yes
No
Maybe
Pastor's Name
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May we contact your pastor?
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Yes
No
Are you certain you are going to heaven?
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Yes
No
Maybe
Part 4 - Five Basic Questions
1. What issues are you struggling with?
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2. What Have You Done About It?
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3. What brings you here at this time?
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4. what do you hope we can accomplish?
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5. is there anything else we should know?
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Thank you for completing this form. Please review your answers and when you are satisfied with your answers, please submit the form.
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