PDI PDI Assessment Name: First Last Birth Date: MM slash DD slash YYYY Address: Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Age:Gender:Choose from the options belowMaleFemaleMarital Status Single Engaged Married Separated Divorced Widowed Highest Education Level:Home Phone:Cell Phone:Email: Employer:Position:Years Employed:Marriage & FamilyName:Spouse First Last Birth Date:Spouse MM slash DD slash YYYY Age:SpouseOccupation:SpouseYears Employed:SpouseHome Phone:SpouseWork Phone:SpouseCell Phone:SpouseDate of Marriage: MM slash DD slash YYYY Length of dating:Meeting & DatingGive a brief statement of circumstances of meeting and datingHave either of you been previously married?Choose from the options belowYesNoIf yes, to whom:Have either of you been separated?Choose from the options belowYesNoFiled for divorce?Choose from the options belowYesNoIs your spouse willing to come for counseling?Choose from the options belowYesNoIs your spouse in favor of your coming?Choose from the options belowYesNoIf no, please explain:Information about ChildrenCreate additional rows for each child by using the "plus" button at the end of the row.Child NameAgeGenderLivingYear EdStep Child? Add RemoveDescribe your relationship to your father:Describe your relationship to your mother:Number of siblings:Your sibling order:Did you live with anyone other than parents?Choose from the options belowYesNoAre your parents living?If yes, list below.HealthDescribe your health:Do you have any chronic conditions?Choose from the options belowYesNoIf yes, please list:List important illnesses and injuries or handicaps:Date of last medical exam: MM slash DD slash YYYY Report:Physician's name and contact information:Current medication(s) and dosage:Have you ever-used drugs for anything other than medical purposes?Choose from the options belowYesNoIf yes, please explain:Have you ever been arrested?Choose from the options belowYesNoDo you drink alcoholic beverages?Choose from the options belowYesNoIf so, how frequently and how much:Do you drink coffee?Choose from the options belowYesNoIf so, how frequently and how much:Do you drink other caffeine drinks?Choose from the options belowYesNoIf so, how frequently and how much:Do you smoke cigarettes or use tobacco products?Choose from the options belowYesNoIf so, how frequently and how much:Have you ever had interpersonal problems on the job?Choose from the options belowYesNoIf yes, please explain:Have you ever had a severe emotional upset?Choose from the options belowYesNoIf yes, please explain:Have you ever seen a psychiatrist or counselor?Choose from the options belowYesNoIf yes, 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?Choose from the options belowYesNoSpiritualDenominational preference:Church attending:Member?Choose from the options belowYesNoDo you believe in God?Choose from the options belowYesNoDo you pray?Choose from the options belowYesNoWould you say you are a Christian?Choose from the options belowYesNoor still in the process of becoming a Christian:Have you ever been baptized?Choose from the options belowYesNoHow often do you read the Bible? Never Occasionally Often Daily Explain any recent changes in your religious life:FinancialApproximate yearly family income:Do you own your home?Choose from the options belowYesNoDo you have significant debt in any of the following areas: Home Car School Credit Cards Are you saving money?Choose from the options belowYesNoDo you give money to your church or other charities?Choose from the options belowYesNoIs money a source of struggle or discomfort in your life?Choose from the options belowYesNoAre you involved in or anticipate being involved in legal actions?Choose from the options belowYesNoWomen OnlyHave you had any menstrual difficulties?Choose from the options belowYesNoIf you experience tension, tendency to cry, other symptoms prior to your cycle, please explain:Your InformationWe are grateful to the LORD for the opportunity to meet with you and sincerely desire to understand what is happening in your life. This checklist is a way for us to gather more information about what is going on in your life. You can check as many boxes as you need.Problem Check List Anger Anxiety Apathy Appetite Bitterness Change in lifestyle Children Communication Conflict (fights) Deception Drunkeness Eating problems Envy Fear Finances Gluttony Guilt Health Homosexuality Impotence Loss of Loved One Lust Memory Moodiness Perfectionism Pornography Rebellion Sex Sleep Spousal Abuse Please Tell Us Your "STOREE"It will be helpful to have at least a few sentences or short paragraph for each letter of STOREE. (If additional space is needed, please feel free to answer the questions in a separate document.) Thank you for your help, and we will be prayerfully anticipating our meeting. Situation: What seems to be the main problem?Thinking: What do you think or wonder about yourself in relations to the situation? What do you think of others in relation to the situation?Others: How are others involved? How does this issue impact others? What have others done to compound or alleviate the problem?Response: What are you doing about the issue? What have you done to try to address the issue in the past? What are your typical actions or reactions to this problem (e.g. "I get angry and go for a drive")? In general, when you are feeling pressure in life, how does it come out? What do you do? How are you sleeping?Emotions: What do you fear? What would give you peace, related to this situation? What is the emotion you are struggling with the most?Desires/Expectations: How do you hope we can help you? What do you want the most related to this situation?Is there anything else we should know? Δ
