Personal Data Inventory – Scott & Meghan Dillon – The Third Place

Personal Data Inventory - Scott

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

Age

Gender

Male

Female

Prefer not to say

Phone Number

Email Address

Highest level of education completed

Current Occupation

Marital Status

How many children do you have?

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.

In a few sentences, describe your relationship with God and your personal experience of faith.

Emergency Contact Information

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? 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 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 prompts.

I understand that Scott Dillon is a current student at Reformed Theological Seminary and that details of my case may be shared with the professor/supervisor and other students without any of my personally identifying information included. (there is a separate Confidentiality Form that must be signed)

I understand that it is required by Reformed Theological Seminary's Counseling program to record, for supervision purposes, a session (with the exception of the first one) and that Scott Dillon will inform me BEFOREHAND if a session is being recorded.

I understand that Scott Dillon is considered a Mandatory Reporter and will contact local authorities if there is an immediate and credible threat of endangerment of another person.

I consent for Scott Dillon and this website to store my submitted information so he can respond to my inquiry appropriately. (your information is not stored on any third-party webhost, ie Google or Microsoft)