pressing forward · web viewpressing forward ministries. counseling . questionnaire. savannah, ga...

Pressing Forward MinistriesCounseling Questionnaire

Savannah, GA 31410

DATE ________________

Name _______________________________________________________________________________

Address ______________________________________________________________________________

City _____________________ST _____ Zip ________ Contact # _______________________________ Cell, Home, Work (circle one)Email address _________________________________________________________________________

PERSONAL INFORMATION

Current Occupation: ___________________________________________________________________

Education (circle last year completed): Grade School 1 2 3 4 5 6 7 8 9 10 11 12

College 1 2 3 4 Masters_____ Doctorate_____ PhD______ Degree _________________________

Additional Training (certificates, courses, etc.) _______________________________________________

____________________________________________________________________________________

Sex____ Birth Date ___________ Age _____ Height ______Ethnic Background ____________________

_____ Widowed _____ Married ____ Separated _____ Divorced _____ Single_____ Living Together

Time Frame of above status: ____________ Prior Marriages, how many? ____________________

Are you living with anyone now and with whom? ____________________________________________

Relationship to the person whom you are currently living with: _________________________________

How would you rate your relationship? __Very happy __Happy __Average __Unhappy __ Indifferent

If married, are your headed for divorce? _____ No ____ Yes If yes, is it salvageable?_____________ _____________________________________________________________________________________

_____________________________________________________________________________________

Room for improvement, how? ____________________________________________________________

Do you love your spouse? _______________________________________________________________

1

Confidential Questionnaire of 13

If not, when and why did you fall out of love? _______________________________________________

_____________________________________________________________________________________

Define the word “contract”: ______________________________________________________________

_____________________________________________________________________________________

Define the word “covenant”: _____________________________________________________________

_____________________________________________________________________________________

Define the biblical definition of submission as you understand it: ________________________________

_____________________________________________________________________________________

If Children are from a prior marriage, prior relationship or current marriage, please circle PM/PR/CM

Gender & Age: ( yrs.) _________________ (PM/PR/CM), ( yrs.) __________________ (PM/PR/CM)

( yrs.) _________________ (PM/PR/CM), ( yrs.) _________________ (PM/PR/CM) Please write on back of this page information for additional children.

How many pregnancies? ______ How many miscarriages? _____ How many abortions? _____

Are there any special issues that you handle on a daily basis with a child or children? ________________

_____________________________________________________________________________________

FORMATIVE YEARS

Mother’s EducationEducation (circle last year completed): Grade School 1 2 3 4 5 6 7 8 9 10 11 12College 1 2 3 4 Masters_____ Doctorate_____ PhD______ Degree _________________________

Father’s EducationEducation (circle last year completed): Grade School 1 2 3 4 5 6 7 8 9 10 11 12College 1 2 3 4 Masters_____ Doctorate_____ PhD______ Degree _________________________

Were your parents married when you were born? ____ Yes ____ No

If no, did they get married at some point? ____Yes ____No

If yes, why did they get married? _________________________________________________________

2


Are your parents still living together? ____Yes ____No, If No, Why _____________________________

_____________________________________________________________________________________

Rate the type of your parent’s marriage. __Very happy __Happy __Avg __Unhappy _ Indifferent

Did your mother work outside the home? ____ Yes ____No

If yes, what was her occupation? _________________________________________________________

Did father work outside the home? ____ Yes ____No

If yes, what was his occupation? _________________________________________________________

Was your mother a “stay at home mom”? ____ Yes ____No

Were you reared by anyone other than your parents, briefly explain? ______________________________

_____________________________________________________________________________________

Describe your relationship with your parents? ___close ___surface ___tolerable ___ estranged

Please write in “M” for mother, “F” for Father, “O” for Other as the person responsible for planning or carrying out the following:

_____ Housework ______ Grocery Shopping _____Cooking _____ Cleaned Kitchen after meals

_____ Finances ______ Home Repair _____ Garbage _____ Vehicle Maintenance _____ Yard Work ______Children’s care _____ Children’s spiritual training _____Vacations

Describe your parent’s relationship? (i.e. mother stayed at home and waited on my father or they shared the responsibility of the family or father carried most of the weight because mother was sick, etc.)

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Did your parents have a faith in God? _____ Yes ____ No

Did your parents or caregiver “practice what they preached”? ___ Yes ___ No

What was their denomination? _______________________________________________________

3


Did your family attend church? ____No ____Yes If yes, how often? _____________________________

Did your mother have a strong faith? ____ Yes ____ No

Did your father have a strong faith? ____ Yes ____ No

Did your mother read the Bible with you as a child? ____ Yes ____ No

Did your father read the Bible with you as a child? ____ Yes ____ No

Was your mother active in her church? ____ Yes ____ No

Was your father active in his church? ____Yes ____ No

Did your parents leave it to the church to teach you about the Word of God? ____ Yes ____ No

At this point in your life would you say that you had one or both parents that loved you and were the kind of parents that you would want to be? ____ Yes ____ No

If No, please explain ____________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Were you a victim of physical, sexual or verbal abuse (if comfortable briefly explain)? _______________

_____________________________________________________________________________________

_____________________________________________________________________________________

Additional comments regarding your parents? _______________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Number of sibling’s ____Brothers ____Sisters

Describe your relationship with your siblings? ___close ___surface ___tolerable ___ estranged

If you could go back and change anything about your childhood what would it be? __________________

_____________________________________________________________________________________

4


SPIRITUAL

Current Church Affiliation/Denominational Preference_________________________________________

Are you saved? ____ Yes ____ No Are you Born Again? ___ Yes ___ No

Have you been baptized ____ Yes ____ No Water Baptism ____ Infant Baptism ____

Do you attend church regularly? ____No ___ Yes, if no is it due to your work schedule? ___Yes ____No

Other reasons for not attending regularly: ___________________________________________________

Do you attend a Bible Study? ______ No ______Yes If yes, how often __________________________

Do your children attend church regularly? _____ No _____ Yes

Are your children saved? _____ Yes ____ No, Add’l Info: _____________________________________

Do your children attend a Bible Study? ______No _____ Yes If yes, how often ___________________

Are you involved with a Ministry? ____ Yes ____ No, If yes, please describe ______________________

_____________________________________________________________________________________

International missions: where & how long: __________________________________________________

_____________________________________________________________________________________

Devotions __Daily___ Weekly ___Monthly ___Never ___ Sparse How much time? ________________

Who is God? __________________________________________________________________________

Who is He to you? _____________________________________________________________________

Who is Jesus Christ? ___________________________________________________________________

Who is He to you? _____________________________________________________________________

Who is the Holy Spirit? _________________________________________________________________

Who is He to you? _____________________________________________________________________

What are the gifts of the Holy Spirit? ______________________________________________________

5


Do you believe all the gifts are active today and applicable for the church? _________________________

_____________________________________________________________________________________

Have you done a spiritual gifts assessment? ___ Yes ___ No

What are your spiritual gifts? _____________________________________________________________

Have you been betrayed by a church family member or clergy? If yes, briefly describe _______________

_____________________________________________________________________________________

Do you have any questions regarding faith, religion, salvation, etc.? ______________________________

_____________________________________________________________________________________

GENERAL INFORMATION

How many hours of TV do you watch daily? ____ Favorite TV shows ____________________________

_____________________________________________________________________________________

Are you a reader? ____ How often? ________ Books read per year? _____Type of books_____________

_____________________________________________________________________________________

If you do not read on a regular basis, would you commit to doing so in order to change your situation?___ Yes ___ No

If you are an avid TV watcher, would you be willing to reduce the number of hours you watch TV in order to change your situation? ____ Yes ____ No

Hobbies/Recreation/ (i.e. crafts, sports, collector)_____________________________________________

____________________________________________________________________________________

_____________________________________________________________________________________

Can you relax? ___ Yes, how? ___________________________________________________________

___ No, why? ___________________________________________________________

_____________________________________________________________________________________

6


When you talk to yourself what are the things that you say (i.e. when you make a mistake do you call yourself stupid, do you tell yourself that you are never good enough, etc. please describe your self-talk)

_____________________________________________________________________________________ _____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

If you talked to others the same way you talk to yourself, do you think you would find yourself alone? ___ Yes ___ No

Do you like who you are? _______________________________________________________________

_____________________________________________________________________________________

Would your spouse/family/friends say you have a good sense of humor? ___ Yes ___ No

Do you have fears about…? Check all that apply: ___ Death, dying ___Fear of deliverance ___ Drowning, water___ Not going to Heaven ___ Fear of evil spirits ___ Loud noises/sirens___ Dying prematurely ___ The future ___ Heights___ Losing loved ones ___ Change ___ Enclosed spaces___ Loss of relationships ___ The unknown ___ Sex or loss of it___ Public speaking ___ Getting bad news ___ Pregnancy/children___ Being criticized/rejected ___ Getting a disease ___ Menopause___ Being inadequate ___ Pain and suffering ___ Ware___ Being humiliated ___ Disfiguration ___ Conflict___ Other races/cultures ___ Doctors/hospitals ___ Fear itself___ Being betrayed ___ Needles or blood ___ Of what God might do to you___ Being abandoned ___ Nightmares ___Not being prepared for retirement___ Being alone ___ Fear of the dark___ Success/failure ___ Fear of evil visions Other fears not listed:___ Being responsibility ___ Poverty___ Dependency ___ Allergic reactions __________________________________ Suspicion ___ Animals/Insects___ People in Authority ___ Natural disasters __________________________________ Being punished ___ Fires___ Being controlled ___ Suffocation _______________________________

7


Please check all that apply to you currently:___ Active ___ Good Natured ___ Introvert ___ Self Conscience ___ Calm___ Ambitious ___ Easy Going ___ Shy ___ Excitable ___ Lonely___ Hardworking ___ Self-Confident ___ Leader ___ Moody ___ Submissive___ Dependable ___ Strong ___ Follower ___ Angry ___ Impulsive___ Trustworthy ___ Extrovert ___ Quiet ___ Sensitive ___ Serious___ Persistent ___ Positive ___ Negative ___ Server ___ Giver

Additional attributes: ______________________________________________________________

Please check all that you have been involved with:( ) American Indian ceremonies, cultic items ( ) Mormonism( ) Angel Worship ( ) Martial arts (Tai chi, karate, yoga, etc)( ) Apparitions, ghosts, poltergeists ( ) Masons, Shriners, Eastern Star, Rainbow( ) Astral projection, aura reading Girls, DeMolay( ) Buddhism: Zen and other forms ( ) New Age thinking, symbols( ) Cartoons, comics, movies, video games w/demonic ( ) Occult music, books, demonic rock music Content: horror, porn, violence ( ) Ouija boards( ) Chanting, mantras, incantations ( ) Pagan religions( ) Charms: horseshoes, rabbit’s foot ( ) Pornography( ) Christian Science teaching (Mary Baker Eddy) ( ) Psychic reading, psychic portraits( ) Clairvoyance, clairaudience, mental telepathy, ESP ( ) Reincarnation( ) Conjuration, channeling, mediums ( ) Rosicrucianism( ) Crystal balls, crystals ( ) Satanism, Satan worship( ) Cultural pagan ceremonies ( ) Science fiction addiction: UFO’s, aliens( ) Course of Miracles, Unity Church teachings ( ) Scientology (Dianetics: Ron L. Hubbard)( ) Déjà Vu ( ) Secret brotherhoods, blood oaths( ) Divination: tarot, fortune telling, tealeaf reading, ( ) Sorcery, pharmakia (excess dependence) Handwriting analysis, palm reading, I Ching, ( ) Spiritism, spirit guides Numerology, false prophecy, Kabala ( ) Statues of idols: incl. idolization of artists, ( ) Drug trips, recreational drugs, alcohol abuse sports hero and movie stars( ) Familiar spirits: necromancy, séances, table ( ) Superstitions: fear of blacks cats, wishing

tapping, mediums (Edgar Cayce, etc.) on a star, walking under ladders, Fri 13th

( ) Fetishes, power objects ( ) Unitarian teachings( ) Hinduism, gurus, Eastern philosophies ( ) Voodoo( ) False prophets (Jeanne Dixon, Nostradamus) ( ) Wart charming( ) Hypnotism, self-hypnotism ( ) Water-witching, geomancy( ) Islam, Black Moslem teachings ( ) Wicca, witchcraft, spells, warlocks, ( ) Jehovah’s Witness, Watchtower teachings witches( ) KKK, racism ( ) Witchcraft/rebellion in the home or( ) Magic; white, black, stage magic church: Jezebel, Ahab and Saul spirits**Please see attached sheet for definition Control and manipulation (rebellion) of terms. Matriarchal and patriarchal witchcraft

8


Have you ever felt as if you were being watched? ____Yes ____No

Have you ever had hallucinations ____Yes ____No

Have you ever been the victim of a crime? __ No __Yes, if so, what? _____________________________

_____________________________________________________________________________________

Have you been convicted of a crime? __ No __ Yes, if so, what__________________________________

_____________________________________________________________________________________

Have you suffered a trauma (death, rape, serious accident, etc.)? ________________________________

_____________________________________________________________________________________

Do you have a problem forgiving? If yes, briefly describe: ____________________________________

_____________________________________________________________________________________

Is there anyone in your life that you have not forgiven? ______________________________________

Are you angry? If yes, do you express anger: ___ outwardly verbal ___ outwardly physical __withdrawn

Define the word Addiction: ______________________________________________________________

_____________________________________________________________________________________

Check the following which you believe are consider to be an addiction:

_____ Tobacco _____TV ____ Exercise _____ Sports _____ Food_____ Gambling _____ Work ____ Appearance _____ Drugs _____ Shopping_____ Computer _____ Anger _____Enabling _____Pornography _____Sex_____ Collector of things

"When the habit interferes with the ability to grow, to learn new things, to lead an active life, then it does constitute a kind of dependence and should be taken seriously."

Define the word Pornography: ____________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

9


MEDICAL/DIET HISTORY

Are you currently under the care of a doctor or Psychiatrist? If yes, please explain ___________________

_____________________________________________________________________________________

Please list all medications? _______________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Have you been hospitalized for emotional illness? ____ No ____ Yes Briefly Describe _____________

_____________________________________________________________________________________

Date of last medical examination: _________ Report:__________________________________________

_____________________________________________________________________________________

Have you used drugs other than for medical purposes: ____No ____Yes, if yes, please explain? ________

_____________________________________________________________________________________

Have you ever had any counseling or psychotherapy? ____No ____Yes, if yes, please list dates,

Counselor or Therapist__________________________________________________________________

_____________________________________________________________________________________

How would you rate your physical health? ___Very Good ___Good ___Average ___Declining

Other (please explain) __________________________________________________________________

_____________________________________________________________________________________

Do you like the way you look? ____ Yes ____ No If no, what would you change? __________________

_____________________________________________________________________________________

How often do you go on a diet to lose weight? ___________________

In the past year, how many diets have you been on? _______________

10


Name the type of diets you have tried? _____________________________________________________

Your approximate weight: ____Any recent changes in your weight? ___No ___Yes If yes, please

explain ______________________________________________________________________________

Are you satisfied with our weight? ___ Yes ___No What would be your ideal weight? _______________

Any recent changes in your weight? ___ Yes ___ No If yes, please explain _______________________

_____________________________________________________________________________________

Do you exercise? __ No __ Yes, if yes – Type____________________ How often? ________________

If you are over 40 and are exercising to lose weight, does it make a difference how much you eat? ______

Under normal conditions, can you lose weight if you don’t exercise? _____ Yes _____No

Is drinking teas and other liquid the same as drinking water? ____ Yes ____ No

How much water do you drink daily? ______________ Can you drink too much water? ___ Yes ___ No

Food preference: _____ Meat & Potatoes _____ Whole Foods _____ Balance between both preferences

_____Low Carb ______No Carb Are you a vegetarian? ___ No ___ Yes ____

If yes, what type? ___ Vegans: one who rejects all forms of animal products including dairy___ Lacto-ovo: one who rejects all meat but will consume dairy products/eggs___ Lacto: one who rejects meat and eggs, will not eat foods with gelatin (made from tissue of animals)

Describe what you think a healthy diet is? ___________________________________________________

_____________________________________________________________________________________

What does the phrase “whole foods” mean? _________________________________________________

_____________________________________________________________________________________

Give 5 examples of processed food: _______________________________________________________

_____________________________________________________________________________________

Give 5 examples of whole foods: __________________________________________________________

11


_____________________________________________________________________________________

Do you eat fast food? ____No ____Yes. If yes, what kind and how often __________________________

_____________________________________________________________________________________

Do you have any food addictions? ___ No ___ Yes If yes, what are they and how often do you consume

them? _______________________________________________________________________________

How much sugar do you consume weekly? _________________________________________________

Do you know that most processed foods contain some type of sugar? ____ Yes ____ No

Do you consume sugar substitutes? ___ Yes __ No, If yes, what and how often _____________________

_____________________________________________________________________________________

What does the term “hydrogenated” mean? __________________________________________________

What does the term “trans fat” mean? ______________________________________________________

Are there biblical guidelines that do or do not support vegetarianism? ____Yes ____No ____Don’t Know

What is a whole food supplement? ________________________________________________________

Do you take vitamins/minerals/food supplements? ___ No ___Yes, if so, what _____________________

_____________________________________________________________________________________

How do you determine/decide what supplements to take? ______________________________________

_____________________________________________________________________________________

Have you had hair/urine/blood analysis to determine a vitamin or mineral deficiency? ___Yes ___ No

Do you have any food allergies? __ No __Yes, if so, what ______________________________________

_____________________________________________________________________________________

Do you overeat? ___Never ___ Sometimes ___ Every meal. Describe what you consider overeating to

be and why you think you do: ____________________________________________________________

_____________________________________________________________________________________

12


How many meals a day do you eat? ________________________________________________________

What does the term “graze” mean? ________________________________________________________

What is oxygen therapy? ________________________________________________________________

What part does oxygen play in our overall health? ____________________________________________

_____________________________________________________________________________________

BRIEFLY ANSWER THE FOLLOWING QUESTIONS

What brought you here? _________________________________________________________________

_____________________________________________________________________________________

What do you see as your main problem? ____________________________________________________

_____________________________________________________________________________________

If married, describe your spouse’s personality in a few words such as selfish, loving, etc? _____________

_____________________________________________________________________________________

As you see yourself, describe what kind of person you are? _____________________________________

_____________________________________________________________________________________

In case of emergency contact _____________________________________________________________

_____________________________________________________________________________________

Printed Name: ______________________________________

Signature: __________________________________________ Date: ______________________

Signature: __________________________________________ Date: ______________________ Angela McCurdy

(If this questionnaire is being completed electronically,then your typed name is considered your legal signature.)

13

PLEASE COMPLETE A QUESTIONNAIRE FOR EACH MEMBER OF THE FAMILY

14

pressing forward · web viewpressing forward ministries. counseling . questionnaire. savannah, ga...

Documents