PDI Form for Ages 14 to 17

Personal Information

First Name:

Last Name:

Address:

City:

Zip:

Phone(H)

(C)

(W)

Email:

Gender:

Birthdate:

Age:

School Name:

Grade

Do you have a job?

Place of Employment:

Referred to The Chapel by:

Health Information

How would you rate your health?

Very Good

Good

Average

Declining

Other

Have you had significant weight changes recently, gain or loss?

Gained Weight

Lost Weight

List any important illnesses, injuries or handicaps that you may have:

Are you presently taking any medications?

Yes

No

Church Activity

Which Chapel Campus do you attend?

CrossPoint

Lockport

Cheektowaga

Niagara Falls

Partner Church

How long have you been attending?

If a Partner Church, which Partner Church?

How long have you been attending?

Do you serve in the church that you attend?

Yes

No

Which ministry do you serve in?

Have you been baptized?

Yes

No

If so approximatly what age were you?

Are you currently involved in a youth group?

Yes

No

Do you believe in God?

Yes

No

Do you believe satan exists?

Yes

No

Do you pray to God?

Never

Sometimes

Often

Daily

How often do you read the Bible?

Never

Sometimes

Often

Daily

Explain any recent changes in your walk with God:

Personality Information

Have you ever had counseling before?

Yes

No

If yes, how many times and how long ago?

If yes, what was the outcome?

As you see yourself, what kind of person are you? Describe yourself:

If anything, what do you fear?

Have you recently suffered a loss from a relationship, social loss, business loss or any other losses? If so, please name it and explain:

Please select the words that best describe you:

Godly

Angry

Abusive

Irresponsible

Proud

Embarrasing

Active

Ambitious

Self-Confident

Persistant

Nervous

Hardworking

Moody

Often-Blue

Likable

Leader

Serious

Easy-Going

Humerous

Disorganized

Self-Conscience

Lonely

Sensitive

Whiner

Failure

Success

Please tell us anything else about your personality that you would like us to know:

Family and Childhood Information

Have you been or are you being raised by anyone other than your biological parents? Please explain:

How many brothers do you have?

How many sisters do you have?

Which number are you in the birth order of you and siblings?

Are you on good terms with your father, mother, siblings? If not, list who you're not on good terms with and why:

List anyone who you hate or are extremely angry with and the reasons:

What kind of home have you grown up in?

Traditional (Father, Mother, Kids)

Authoritarian (Father or Mother made all rules w/out discussion and would not allow for opionions.)

Single or Divorced Parents

Alcoholic (One or Both Parents or sibling alcohol addicted)

Drug Affected (One or Both Parents or sibling drug addicted)

Perfectionist (Everything needed to be perfect to please Mom or Dad)

Critical (One or both parents always commented on negatives and offered little praise for the good)

Affectionate (Free with hugs and kisses)

Emotional (Crying and/or anger freely allowed)

Repressed (Emotions never allowed to show)

Religious (For real, not faked for appearance. A real realtionship with God)

Fake Religious (Only religious for appearance, but behind closed doors no real relaationship with God)

Step Family (One or both parents remarried)

Abusive (Verbal, Emotional, Physical, Sexual)

If you know, please explain what type of home your father grew up in:

If you know, please explain what type of home your mother grew up in:

How would you describe your fathers personality? (ex. Godly, Worldly, Strict, Easy-Going, Moody, Calm, Serious, Humerous, Lazy, Hard-Working etc.)

How would you describe your mothers personality? (ex. Godly, Worldly, Strict, Easy-Going, Moody, Calm, Serious, Humerous, Lazy, Hard-Working etc.)

Where did you grow up? What type of place was it? (ex. Urban, Suburban, Rural):

What is your families economic situation?

Extermely poor

Poor

Lower middle

Middle

Higher middle

Wealthy

Exteremly Wealthy

What has been your happiest memory?

What has been your unhappiest memory?

Which parent do you feel closest to and why?

Have you experience a major trauma? (ex. at home, at school, at a neighbor's home, at a relatives home. Please explain:

Television and Entertainment

How much time per day do you spend using technology that is not work or school related? (phone, computer, tablet, video games) in hours:

1 Hour - 3 Hours

4 Hours - 6 Hours

7 Hours - 9 Hours

10 Hours - 12 Hours

13 + Hours

How many hours of television do you watch each day?

1 Hour - 3 Hours

4 Hours - 6 Hours

7 Hours - 9 Hours

10 Hours - 12 Hours

13 + Hours

List out your favorite shows/movies/video games:

What is your favorite type of music?

List your favorite entertainers:

Bio-Psychological Information

Have you ever felt people were watching you?

Yes

No

Do peoples faces ever seem distorted to you?

Yes

No

Do you ever have trouble distinguishing peoples faces?

Yes

No

Do colors ever seem to bright?

Yes

No

Are you sometimes unable to judge distance?

Yes

No

Have you ever had hallucinations?

Yes

No

Are you afraid of being in a car?

Yes

No

Is your hearing exceptionally good?

Yes

No

Do you have problems sleeping?

Yes

No

Personal Behavior Habbits

Do you drink coffee or other caffenated drinks?

Yes

No

If yes, how much per day?

Do you smoke/vape or chew tobacco products?

Yes

No

If yes, how much per a day?

Do you do pot or other drugs?

Yes

No

If yes, how often?

Never

Occationally

Often

Very Often

Do you drink alcohol?

Yes

No

If yes, how often?

Never

Occationally

Often

Very often

Do you ever explode when you get angry?

Yes

No

Do you withdraw when you get angry or hurt?

Yes

No

Do you frequently ague with people?

Yes

No

Briefly Answer the Following

What issue(s) may we help you with?

What steps have you taken in the past to deal with your issue(s)?

What do you expect to accomplish with our help?

Is there any other information that we should know?

Problem Check List (Check all that are current for you):

Anger

Envy

Appetite

Anxiety

Fear

Memory

Apathy

Gluttony

Moodiness

Bitterness

Guilt

Rebellion

Change in lifestyle

Health

Sex

Children

Parents

Homosexuality

Sleep

Depression

Impotence

Abuse

Deception

In-laws

A vice

Which one(s) of the above seem to be most dominant?

Our available office hours for appointments are Mondays and Fridays from 9am - 5pm and Tuesday, Wednesdays and Thursdays from 9am to 8:00pm. What days and hours would you be available for an appointment?

BIBLICAL COUNSELING INFORMATION AND COVENANT

1. Diagnostic Tools: We use helpful counseling forms such as this Personal Data Information form and other aids to gain an understanding of the central problems a person is experiencing.

2. Intent Listening: We encourage the counselee to speak his/her mind in an appropriate fashion and to discuss thoughts, anxieties, resentments, and fears so that the counselor will have a clear understanding of the central problems.

3. Assignments: Counselees make more rapid progress when they are required to study or to perform specific informational or behavioral assignments which pertain to the problem. We tailor these assignments to the individual counselee and the circumstances.

4. Accountability: We are not interested in wasting the time of the counselors or the counselees. We are interested in believers learning how to experience the peace and joy that result from a walk of thankful obedience to God's Word, and we hold the counselees accountable for doing the assignments on schedule.

How long does biblical counseling take?

Biblical Counseling will vary in the amount of time required according to the individual, his motivation, and the particular problem. Typically, that would be between five and eight weeks. On the average, however, biblical counseling requires far less time than conventional secular counseling. One reason is that biblical counselors are not interested in prolonging the number of sessions in order to increase their income.

How much does it cost?

Biblical Counseling is a ministry of The Chapel available for those who attend one service a week and/or attend one of The Chapel' Partner Churches. Biblical Counseling is provided for those at no cost. Donations to the Counseling Ministry are always welcome.

About confidentiality

We are careful to protect each counselee's confidentiality. There are times, however, when a counselor must consult with other counselors for advice. If information is revealed in counseling which indicates a genuine potential for harm to a counselee or others, the counselor may be required by law or biblical mandate to share that information with the appropriate authorities or family members.

The Chapel is on mission to reach every Man, Woman & Child with repeated opportunities to hear and see the Gospel of Jesus Christ

BIBLICAL COUNSELING COVENANT

I affirm the accuracy of the personal information provided herein, and have read the information above and agree to the conditions set forth therein. I hereby agree to the following conditions:

1. I will keep the appointment time, or will call to cancel in advance with a legitimate reason.

2. I will fulfill any assignments.

3. I will attend The Chapel each Sunday while I am in counseling.

4. I understand that confidentiality cannot be guaranteed in the case of information as indicated above.

Signed by youth

Date

Signed by Parent or Guardian over the age of 18.

Date