New Client: Personal Data Inventory – Scott & Meghan Dillon – The Third Place

There are three stages to becoming a new client:

Fill out the Personal Data Inventory (this page)
Sign the Telemental Health Consent form (next page)
Schedule your first session (last page).

Personal Data Inventory

Please complete the Personal Data Inventory You can scroll down to see availability before you decide, but please remember that you must complete the PDI before the first session.

Personal Data Inventory – Meghan

General Information

All information is confidential and securely saved in the site’s database. There is no third party access or sharing of this information.

First Name

Last Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Nationality

Age

Cedula/Passport/ID #

Gender

Male

Female

Prefer not to say

Emergency Contact Information

Phone Number

Email Address

Highest level of education completed

Current Occupation

Marital Status

Spouse’s Name

How long have you been married?

If you attend a church, where do you attend?

Are you member at your church?

List any minsitries at church in which you’re involved.

Do you have a person(s) to whom you are accountable at your church? Explain:

Do you believe being an active part of a community of believers is important to reaching your goals in counseling? Why or why not?

If you know your Enneagram type, which is it:

If you know your Myers Briggs Personality Type, which is it:

Family & Marriage Information

Please provide some background on your immediate family. (only applies to married applicants and/or parents)

If married, did you receive marriage counseling? If yes, please provide some detail.

Have you or your spouse ever filed for divorce? If yes, please provide some detail.

If married, have you or your spouse ever been separated? If yes, please provide some detail.

If previously married, please provide some background on previous marriages.

List the names and ages of your children. Also mention if they are: 1) living at home, 2) Special relationship (stepchild, adopted, etc)

Medical Information

Please provide some medical background that will help us discuss any concerns and issues you might have.

Do you have any consistent medical troubles? Illnesses, allergies, etc. If so, please explain.

Please list any medications you’re taking and why you’re taking them:

Have you or an immediate family member ever been diagnosed with a psychological or psychiatric disorder? If so, please describe.

How many hours of sleep do your normally get?

How much do you exercise?

Have you ever seen a counselor or therapist for anything? Briefly describe your experience.

How many hours a day do you spend looking at screens (TV, Video Games, Social Media, etc)

How often do you consume caffeinated beverages?

How often do you consume alcoholic beverages?

Have you ever been arrested and/or incarcerated? If yes, please provide some detail.

How often do you consume recreational drugs?

How often do you consume pornographic material?

Family History

Tell me about your upbringing and current family.

Mother: Describe your mother when you were a child. Check all that apply.

Leader by Example

Balanced Authority

Caring and Involved

Performance Driven

Excessively Authoritative

Excessively Permissive

Manipulative

Strict or Rules Driven

Disengaged or Distant

Emotionally or Physically Abusive

Substance Abuse

Father: Describe your father when you were a child. Check all that apply.

Leader by Example

Balanced Authority

Caring and Involved

Performance Driven

Excessively Authoritative

Excessively Permissive

Manipulative

Strict or Rules Driven

Disengaged or Distant

Emotionally or Physically Abusive

Substance Abuse

Did you grow up with your parents?

Yes

If not, please provide some detail.

Are your parents still married?

Yes

If not, please provide some detail.

Are your parents still living?

Both

Just Dad

Just Mom

Neither

Have their been any deaths in your family in the last year? If so, please describe what happened.

Is there anything else that would be helpful to know from your childhood?

Area of Difficulties/Struggles

Please tell me about the areas of your life in which you’re having some struggles.

In just a few sentences, how would you describe the issues facing you today? What brings you to see a counselor?

When did these issues begin?

What are some ways you have dealt/coped with the current situation?

As you are comfortable, select all of areas of difficulty that you’re facing from the dropdown:

Final Agreements

Please read carefully the following information:

Meghan Eileen Dillon is an intern counseling student, finishing her master’s in Clinical Mental Health Counseling at Liberty University. She offers counseling as part of her Masters program and works under the supervision of Kelly Marie Baxley, who has a Master of Arts in Counseling from Covenant Theological Seminary. Kelly is a Licensed Professional Counselor and her license number is 2017017271. They are also under the authority of the elders of the United Church of Bogotá (UCB).

Meghan provides counseling based on Biblical principles and she is a Christian counselor. It is Meghan’s intention to work with each client in a manner that, though shaped by and impacted by her faith, will help them toward their intended goals, though they may not share that same faith. She is not recognized as a therapist or psychologist in Colombia and will refer clients to the right professional if their issue is outside of her scope of practice. Under certain circumstances, she may choose to work alongside a psychologist or psychiatrist and accompany their professional work.

I understand Meghan Dillon’s credentials and qualifications as stated above and that she is practicing in Colombia as a Christian counselor student intern, a ministry of UCB.

I understand that, at any time, I can terminate the counseling relationship. If I have a concern or complaint about my counselor, I am free to discuss those concerns with her. If I have a concern or complaint about my counselor’s practice in any way, I am free to discuss those with any of the elders at UCB.

I understand one of the goals of the counseling I will receive is to confront personal and interpersonal issues and painful emotions. There is a possibility that during the counseling process some emotional and interpersonal symptoms may worsen before they get better. Other resources will likely be suggested during the counseling process and that these are key to reaching my goals in a timely manner (articles, books, etc.)

I understand payments received are donations due to UCB when services are rendered. These donations go directly to the church and are not received by the counselor. My donation for counseling helps me be more invested in my own personal growth. I understand UCB does not file insurance claims nor receive insurance payments.

I understand my appointment time is reserved exclusively for me and that I will do my best to cancel at least 24 hours in advance to respect the time of my counselor. My counselor does not provide counseling via email or WhatsApp and that all email or WhatsApp correspondence with my counselor will not involve the giving of advice or counsel, nor should it be expected to address sensitive issues.

I understand that for any number of unforeseen reasons I cannot get in touch with my counselor and I feel unable to keep myself safe, I will need to go to my local hospital emergency room, or contact emergency services in my local area. My counselor will make every attempt to inform me in advance of planned absences and will provide me with the name and phone number of the counselor/pastoral staff covering for him/her.

I understand my counselor works alongside the leadership of UCB and therefore my counselor is free to collaborate and consult with the Elders, Deacons, or other church staff members as deemed necessary. Any consultation or collaboration will be done in the client’s best interest and only crucial information will be disclosed or sought out to offer a more holistic approach to counseling.

I understand my counselor will break confidentiality for any of the four following reasons: ● If I am an immediate danger to myself and others, ● If I intend homicide or suicide, ● If a child, elderly person, or disabled person is being abused or has been abused, ● If emotional harm or abuse is being caused by the client to anyone at UCB.

I understand I may be required to sign a release of information so my counselor can collaborate with other therapists outside of UCB to provide collaborative treatment.

I give my counselor permission to discuss my case with her supervisor, Kelly Baxley, in a clinical manner as this is a requirement for her internship.

Please digitally sign this form by writing your full name in the box below.

Signature