Skip to content
PDI Form
BSC - PDI Form
Name
*
Name
First
First
Last
Last
Health Information
In this section, we'll ask you to provide some basic information about your current physical health. We ask for this information because sometimes physical symptoms can be an indicator of, or factor in, emotional distress. Additionally, understanding your current health can help us determine the best plan of care for you moving forward. Please answer the following questions as truthfully and accurately as you are able.
How would you describe your general health?
*
Good
Average
Poor
Other
How often do you exercise?
*
Every day
5-6 times per week
3-4 times per week
1-2 times per week
Never
Do you have any difficulties with sleeping?
*
Yes
No
How many hours of sleep do you typically get each night?
*
1
2
3
4
5
6
7
8
9
10
11
12+
How would you describe the food you typically eat each day?
*
Very Healthy
Mostly Healthy
Mix of Healthy and Unhealthy
Mostly Unhealthy
Very Unhealthy
How often do you drink coffee, tea, soft drinks, or other caffeinated beverages?
*
5+ times per day
3- 4 times per day
1-2 times per day
Never
How often do you drink alcohol?
*
14+ drinks per week
7-13 drinks per week
4-6 drinks per week
1-3 drinks per week
Never
How often do you smoke tobacco?
*
Every day
A few times per week
Once a week
A few times per month
Less than once a month
Never
If you would like to add any explanation or clarification to the previous questions, you may do so here.
Do you take any prescription medication?
*
Yes
No
Please list each medication you are taking along with the corresponding dosage.
Medication
*
Dosage
*
plus1
Add
minus1
Remove
Have you ever used prescription drugs for non-medical purposes?
*
Yes
No
Have you ever used, or been addicted to, any illegal drugs (including marijuana)?
*
Yes
No
What was the date of your last physical exam
*
(use your best guess if you are unsure)
Did any of the results from your last physical exam concern you or your physician?
*
Yes
No
If yes, please explain.
*
Background Information
In this section, we'll ask you to provide some information about your family history, upbringing, and personal history. Please answer the following questions as truthfully and accurately as possible.
Other than your parent(s), did you have any other significant role models in your life while growing up?
*
Yes
No
If yes, please explain.
*
Are (or were) your parents divorced?
*
Yes
No
If yes, what age were you when your parents were divorced?
*
How would you describe your home atmosphere while growing up? Check all that apply.
*
Affectionate
Authentically Christian
Critical
Hostile
Outwardly Religious
Perfectionistic
Other
Other
Were you abused in your past?
*
Yes
No
If yes, please explain.
*
To the best of your knowledge, was there substance abuse in your family?
*
Yes
No
If yes, please explain.
*
Did you have any significant traumatic events as a child or have you ever had an extreme emotional reaction to a situation in your life?
*
Yes
No
If yes, please explain.
*
How would you describe yourself? Check all that apply.
*
Angry
Anxious
Depressed
Despairing
Easy Going
Excitable
Fearful
Impatient
Impulsive
Lonely
Moody
Rejected
Self-Conscious
Sensitive
Serious
Shy
Other
Other
Have you ever had any counseling or psychotherapy?
*
Yes
No
If yes, please list when, where, and with whom.
*
Faith Background
In this section, we're looking to gather some information about your background as a Christian and your overall spiritual health. There are no right or wrong answers here, and your answers won't immediately qualify or disqualify you for care. We simply ask that you answer as truthfully as possible so that we can better determine how to care for you moving forward.
Would you consider yourself to be a Christian?
*
Yes
No
When did you put your faith in Jesus Christ as your Lord and Savior?
*
Have you been baptized?
*
Yes
No
If yes, when were you baptized?
*
How often do you read the Bible?
*
Every Day
5-6 times per week
3-4 times per week
1-2 times per week
Less than once a week
Never
How often do you pray?
*
Every Day
5-6 times per week
3-4 times per week
1-2 times per week
Less than once a week
Never
Do you volunteer at Harvest?
*
Yes
No
If yes, how do you serve and at which campus?
*
Additional Information
In this final section, we would like to gather some additional information about the issue you are facing, why you chose to seek counseling, and what steps you've taken so far to address the problem. Again, there are no right or wrong answers here, but by answering truthfully, you'll help us learn how to better address your issue and help care for you.
From your perspective, what is the problem you are wanting to address through counseling?
*
What have you done so far to address the problem?
*
How can we help? What are your expectations in coming to counseling?
*
What, if anything, do you fear?
*
Name some key individuals who you feel have influenced you either currently or in the past (note good or bad).
*
Please describe any significant life events that you feel have influenced you either positively or negatively.
*
Is there any other information you feel your counselor should know?
*
If you are human, leave this field blank.
Submit
