Please answer the following questions as they apply to your life:
Homosexual tendencies?:
Yes No
Participated in college fraternities or sororities?:
Yes No
Feelings of guilt and shame?:
Yes No
Hopelessness?:
Yes No
Fatigue without medical reason?:
Yes No
Abortion?:
Yes No
Difficulty in forgiving?:
Yes No
Is there bitterness, anger, or unforgiveness?:
Yes No
If so, can you forgive?:
Yes No
Do you hate yourself?:
Yes No
Have you suffered from self harm?:
Yes No
Do you have feelings of gloom?:
Yes No
Do you feel rejected?:
Yes No
Do you have any objects in your home or possession that relate to ungodliness or cults, this would include new age religions, such as books about eastern deities, crystals, heavy metal music, Native American artifacts, wiccan, etc.?:
Yes No
If Yes, can you give examples?:
Ever “felt” a presence in the room?:
Yes No
If Yes, has it been recently?:
Yes No
If either question was Yes, please explain:
Do you have nightmares?:
Yes No
If Yes, do you hear voices?:
Yes No
If either question was Yes, please give an example:
Have you been diagnosed by a doctor as having: (list any diagnosis, diabetes, asthma hypertension, etc.)?:
Yes No
If Yes, list the diagnosis here:
Do you have inexplicable pain…no medical explanation for it?:
Yes No
Do you have difficulty in trusting others?:
Yes No
If Yes, do you know why? Please explain:
Has there been a death of someone close to you?:
Yes No
Do you feel like you have any eating disorders?:
Yes No
If Yes, do you know when they begin? Please give approximate height and weight:
Do you suffer from sleep disorders?:
Yes No
Any other medically defined disorder?:
Yes No
Is there a history of tuberculosis, diabetes, ulcers, cancer, heart disease, glandular problems, asthma, other in your family?:
Yes No
Did you have imaginary friends as a child?:
Yes No
If Yes, what were their names:
When attending Church or other ministries do you have “foul” thoughts, jealousies or other mental harassment?:
Yes No
Do you have difficulty retaining God’s Word?:
Yes No
Difficulty in reading it?:
Yes No
Do you have migraine headaches?:
Yes No
Do you have any addictions?:
Yes No
Were you ever diagnosed with a learning disability i.e. (A.D.D.), etc?:
Yes No
Do you have a fear of death?:
Yes No
Have suicidal thoughts?:
Yes No
Has there been a period of time in your life when you were angry with God?:
Yes No
Do you have a fear of losing your mind?:
Yes No
Anxiety or panic attacks?:
Yes No
If Yes, when did they begin?:
Do you feel incredible loneliness?:
Yes No
Are you plagued with doubt and unbelief?:
Yes No
Do you feel inferior?:
Yes No
Do you have thoughts of inadequacy?:
Yes No
Do you have obsessive thoughts?:
Yes No
Blasphemous thoughts?:
Yes No
Compulsive thoughts?:
Yes No
Lustful thoughts?:
Yes No
Do you daydream?:
Yes No
Are you a perfectionist?:
Yes No
Are things seemingly always out of order?:
Yes No
Do you feel the need to be in control?:
Yes No
Are you rebellious?:
Yes No
Insecurity? (On a scale of 1-10 with 10 being worst)?:
Note: denotes a required field.