Pre-Engagement/Pre-Marital PDI Form

Personal Information

First Name:

Last Name:

Address:

City

Zip Code

Occupation:

Place of Employment:

Phone (C):

Phone (H):

Phone (W):

Email:

Gender:

Male

Female

Birthdate:

Age:

Boyfriends/Girlfriends/Fiances Name:

What type of Counseling are you seeking:

Pre-Engagement

Pre-Marital

If Pre-Marital, do you have a date set?

Yes

No

If yes, what is the date?

Pastor performing the ceremony is?

Referred to The Chapel By:

Church Activity

If you attend The Chapel, which Campus have you been attending:

CrossPoint

Lockport

Cheektowaga

Niagara Falls

-How long have you been attending:

Do you attend a Chapel Partner Church:

Yes

No

-Which church:

Do you serve in the church that you attend:

Yes

No

-In what capacity do you serve:

Have you been baptized:

Yes

No

-If you have been baptized, approximatly at what age were you:

Are you currently involved in a small group:

Yes

No

Do you believe in God:

Yes

No

Do you believe satan exists:

Yes

No

How often do you pray to God:

Never

Sometimes

Often

Daily

How often do you read the Bible:

Never

Sometimes

Often

Daily

Relationship Information

How long did you know each other before dating:

Length of dating:

Length of engagement, if engaged:

Have you ever been married before:

Yes

No

-If so, when:

-How long:

-When and how was the marriage ended:

Death of Spouse

Divorce

Do you have children:

Yes

No

What is/are the childs/childrens age(s):

Any other pertinent information:

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

Personality Information

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

What if anything, 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

If you were raised by anyone other than your biological parents, please explain:

How many older brothers do you have:

How many younger brothers do you have:

How many older sisters do you have:

How many younger sisters do you have:

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

Are you on good terms with your Mother, Father, Siblings? If not list who your not on good terms with and briefly why:

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

What kind of home did you grow 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 your family was abusive, what form of abuse (choose all that apply):

Verbal

Emotional

Physical

Sexual

Other

If you were abused, please explain by whom and anything you wish to share about it:

What type of home your father grew up in:

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.)

What was your families economic situation when you were a child:

Extermely poor

Poor

Lower middle

Middle

Higher middle

Wealthy

Exteremly Wealthy

What was your happiest memory as a child:

What was your unhappiest memory as a child:

Which parent did you feel closest to and why:

Did you experience a major trauma when you were a child (ex. at home, at school, at a neighbor's home, at a relatives home. Please explain:

Television and Entertainment

How much non-work related, non-television screen time do you get a day (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 a day?:

Do you smoke 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

In addition to pre-engagement or pre-marriage are there any issue(s) that we may help you with?

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

What do you hope 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

Future 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 7:30pm. When would you be available for an appointment during those times?

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?

Typically pre-engagement is 3 weeks and pre-marriage is 4 weeks unless you and the counselor see benefit in more.

How much does it cost?

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

COUNSELING CONVENANT

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 24 hours in advance or as soon as possible in an emergency 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:

Date: