Personal Data Inventory Personal Data Inventory - ScottGeneral InformationAll 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 AddressAddress Line 1 Address Line 2 City State Zip Code Country Select CountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelauBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongo (Brazzaville)Congo (Kinshasa)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSão Tomé and PríncipeSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (Dutch part)Saint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUnited States (US) Virgin IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabweAge Gender Male Female Prefer not to sayPhone Number Email Address Highest level of education completed - Select -No Formal SchoolingGrade SchoolHigh SchoolSome College but no degreeAssociate's DegreeBachelor's DegreeGraduate Master'sDoctoral DegreeCurrent Occupation Marital Status - Select -SingleDivorcedSeparatedCommon-Law SpouseEngagedMarriedWidowedHow many children do you have? If you attend a church, where do you attend? Emergency Contact Information If you know your Enneagram type, which is it: If you know your Myers Briggs Personality Type, which is it: Medical InformationPlease 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? - Select -Not at all1-3 times a month1-3 times a week5-6 times a weekDailyHave you ever seen a counselor or therapist for anything? Briefly describe your experience. Family HistoryTell 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 AbuseFather: 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 AbuseIs there anything else that would be helpful to know from your childhood? Considering your family today, how would you describe them? If you are married/divorced or have children, describe your relationships today. Area of Difficulties/StrugglesPlease 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: Emotional IntimacyParentingTheftMarital DifficultiesObessions and CompulsionsEmotional AbusePhysical AbuseSpiritual AbuseSexual AbuseFinancial AbuseCodependencyAnger/ControlGuilt/ShameGrief and LossSelf-HarmSuicidal ThoughtsInsecurityRelationship to FoodLying/ManipulationInsomniaChronic IllnessDepressionSubstance AbusePornographyAdultery/Pre-Marital SexSame-Sex AttractionGender DysphoriaSexual IntimacyInfertilityChild Sexual Attraction/Pedophilia Final AgreementsPlease 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)Submit