Center for Biblical Coaching

Personal Data inventory (Teens)

Identification Data

1. Your NameRequired
2. Sex Male Female
3. BirthdateRequired
4. Status Single Going Steady Separated Divorced Widowed
5. Email
6. AddressRequired
7. CityRequired
8. StateRequired
9. ZipRequired
10. OccupationRequired
11. PhoneRequired
12. Education (last year completed)Required
13. Other training (list type and years)
14. Referred here byRequired

Health Information

1. Rate your health Very good Good Average Declining
2. Have you had any significant weight changes recently? Yes No
3. List all important present or past illnesses, injuries or handicaps
4. Date of last medical examination
5. Report from that examination
6. Are you presently taking medication? Yes No
7. If yes, what medication?
8. Have you ever had a severe emotional upset? Yes No
9. If yes, explain

Religious Background

1. Denominational preferenceRequired
2. Are you a member? Yes No
3. Church attendance per month 0 1 2 3 4 5 6 7 8 9 10+
4. Religious background of spouse (if married)
5. Do you consider yourself a religious person? Yes No Uncertain
6. Do you believe in God? Yes No Uncertain
7. Do you pray to God? Often Occasionally Never
8. Are you saved? Yes No Uncertain
9. How much do you read the Bible? Often Occasionally Never
10. Do you have regular family devotions? Yes No
11. Explain recent changes in your religious life, if any

Personality Information

1. Have you ever had any coaching, psychotherapy or counseling before? Yes No
2. If yes, explain
3. Describe your personalityRequired
4. Have you ever felt people were watching you? Yes No
5. Do people's faces ever seem distorted? Yes No
6. Do you ever have difficulty distinguishing faces? Yes No
7. Do colors ever seem too bright or to dull? Yes No
8. Are you sometimes unable to judge distance? Yes No
9. Have you ever had hallucinations? Yes No
10. Are you afraid of being in closed in spaces? Yes No
11. Is your hearing exceptionally good? Yes No
12. Do you have problems sleeping? Yes No

Family Information

1. Name of parentsRequired
2. Address (if different than yours)
3. City
4. State
5. Zip
6. Phone
7. Parent's religionRequired
8. Do you live with both biological parents? Yes No
9. If no, who do you spend the most time with?
10. If you were reared by anyone other than your parents, briefly explain
11. How many older brothers do you have?
12. How many older sisters do you have?
13. How many younger brothers do you have?
14. How many younger sisters do you have?

General Questionnaire

1. What are some of your hopes/dreams for the future?Required
2. What are you doing now to help make these goals a reality?Required
3. What is/are the main problems, as you see it? Required
4. What have you done about it?Required
5. What do you fear? What do you tend to worry about?Required
6. What can a coach do? What are your expectations in having a coach?Required
7. Describe your motivation for wanting changeRequired
8. What are your three strongest talents? (Please explain)Required
9. What are your three weakest areas? (Please explain)Required
10. In writing your epitaph, what would you want people to remember about you?Required
11. What are you doing in your life now that will last forever?Required
12. Please write any other pertinent information you'd like your coach to knowRequired

 

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