___________________________________________
___________________________________________
___________________________________________
___________________________________________
___________________________________________
PURPOSE OF THIS QUESTIONNAIRE
The purpose of this questionnaire is to obtain a comprehensive picture of your background. By completing these questions as fully and accurately as you can, you will facilitate your therapeutic program. This questionnaire will save you both time and expense. You are requested to answer these routine questions on your own time, instead of using up your actual counseling time.
It is understandable that you might be concerned about what happens to the information about you, because much or all of this information is highly personal. Case records are strictly confidential. No outsider , not even your closest relative or family doctor is permitted to see your case record without your written permission.
IMPORTANT: If you do not desire to answer any question, write "Do not care to answer". Also, if some particular question does not apply to you, simply write "N/A" in the space provided.
DATE: _________________________ .
GENERAL
INFORMATION
A. Name
_______________________________________________________________________________
B. Address ______________________________________________ Phone Nos. where you can be
reached._______________________________________email:_____________________
City _______________________ Province___________________ Area Code __________________
E. Religion _______________________ Attendance: Regular Occasional Never (Circle one )
F. With whom are you now living? (List people, their names, ages and
occupations. If they are students, indicate what grade. )
_______________________________________________________________________________________
_______________________________________________________________________________________
G. List 3 people not mentioned in F above who are important to you -
people who are
_______________________________________________________________________________________
_______________________________________________________________________________________
H. How strongly do you want treatment for your
problem? (Circle
One)
Very much Much Moderately Could do without, if necessary _________
OCCULTIC COUNTERFEIT RELIGION INVENTORYBefore you start this step to freedom and wholeness in
OCCULT AND PSYCHIC:
Has there been any personal or family involvement, “scientific” or otherwise, in the following?
Activity Me Fam Sp Activity Me Fam Sp
Astrology 1
Ching
Clairvoyance Metaphysics
Crystal
Ball Numerology
Horoscopes Palm
Pendulum Planchette
White
Magic Psychic
Powers
Dungeons
& Dragons Table
Tipping
Tarot
Cards Tea
Leaves
Telekinesis
(fork bending) Telepathy
Water
Divining Yin-Yang
Wicka
(Good Witch) Other
(This
will include whether you were present in the womb at any activities.)
Activity Me Fam Sp Activity Me Fam Sp
Astral
Flight/Projection Levitation
Psychic
Power Medium
(trying to be)
Spiritism
(ualism) Voodoo
Seances 27
Witchcraft (Rebellion)
Satanism Other
Black Arts
VISITING PLACES OF OCCULT OR PSYCHIC SIGNIFICANCE:
Activity Me Fam Sp Activity Me Fam Sp
Druid
Temples Oriental
Temples
Concentration
Camps Native
Sweat Lodges
Museums
of Torture Occult
Museums
Occult
Shrines Other
OCCULT OR PSYCHIC HEALING:
(Any personal or family involvement in the following which are known to have occult or psychic origins?)
Activity Me Fam Sp Activity Me Fam Sp
(Muscle
testing)
“Applied”
Kinisiology Healing
Stones
Acupressure/Acupuncture Homeopathic
Medicines
28
Healing/Therapeutic
Touch Reflexology
Bach
Remedies Hypnosis
Coloured
Rods Iriscopy
(eye diagnosis)
Pyramids
Radionics
27 1
28 Based on supposed meridians or tracks of energy
that flow through the body. The need to
balance and centre this “chi” or “energy” is the basis of this healing
practice. This energy is referred to as
the cosmic energy of the universe, which needs to flow through the body organs
to maintain health. (Based on Taoist
practice and philosophy).
The increasing evidence of the New Age Movement in all walks of our society comes clearly under the umbrella of Occult & Psychic, because the forces behind it in all its forms are satanic. What, if any, has been your interest in contact or involvement with the New Age Philosophy?
Activity Me Fam Sp Activity Me Fam Sp
One
World Religion One
World Order
All
religion leads to God Eastern
mysticism
New
Age business course New
Age therapies
Man
is divine/Self is God One
World Government
EST/Pursuit
of Excellence Other
SUPERSTITIONS:
(By you or the family as to protection from danger, evil, etc.)
Activity Me Fam Sp Activity Me Fam Sp
Omens Rabbit’s
Foot
Amulets
Bracelets
for luck Unicorns
Brooches
for luck Protective
Cross
Good
Luck Ornaments Zodiac
Charms (wearing)
Pagan
Fetishes Zodiac
Charms (wearing)
Mutilation Branding
Piercing Tattoos
Fortune
Cookies Other
NOTE:
Tattoos: Can give a legal right for a spirit of poverty; spirit of infirmity; of confusion.
SECRET COMMITMENTS:
Have you or your family made any secret commitments in any way?
Activity Me Fam Sp Activity Me Fam Sp
Knights
of
Beta
Sigma Phi Eastern
Star
Blood
Pacts Freemasons
Buffaloes Job’s
Daughters
Druids Nationalist
Groups
HERESIES AND SECTS:
Have you or your family joined, accepted or taught the beliefs of any of these?
Activity Me Fam Sp Activity Me Fam Sp
Anthroprosophy Christian
Science
Bahai Jehovah’s
Witness
Children
of God Eckankar
Christadelphians Karma
Moonies Reincarnation
White
Supremacy Unitarian
OTHER WORLD RELIGIONS:
Have you or your family joined, accepted or taught the beliefs of any of these?
Activity Me Fam Sp Activity Me Fam Sp
Ancestor
Worship Confucianism
Animism Hare
Krishna
Black
Muslims Hinduism
Buddhism
(Zen Buddhism) Islam
Mormonism Other
Satanism
ORIENTAL MIND OR BODY TRAINING:
Have you or your family any involvement in:
Activity Me Fam Sp Activity Me Fam Sp
Tai
Chi Martial
Arts
Yoga
TM
Other
INTELLECTUAL AND RELIGIOUS:
Has there been active denial of or teaching against the following:
Centrality
of the Cross Reality
of
Deity
of
His
Bodily Resurrection Second
Coming
Holy
Spirit The
Trinity
Reality
of Evil Spirits Other
LITERATURE AND MUSIC:
Are there any books, tapes, CD’s, or articles in you or your family’s possession on the above matters by writers advocating quasi-Christian or other activities, religions or belief to which you previously adhered? P.S. If you have these books, etc., for information only, I would advise you to pray and ask the Lord for discernment as to the possibility of these books attracting unwelcome evil/demonic spirits into your house.
OTHER ACTIVITIES WITH POSSIBLE PSYCHIC CONNECTIONS
THROUGH ADDICTIONS:
Activity Me Fam Sp Activity Me Fam Sp
Alcohol Horror
Films/Stories
Drugs Obsessions
Fantasy
Games (D & D) Overeating/Under-eating
Gambling Tobacco
Heavy
Rock Music Lotto
Bingo Other
EXPERT DOAGNOSIS:
Have you or your family had expert diagnosis by a “qualified” person (doctor, specialist, teacher, clergyman, parent) that has projected some negative aspect of your life? ______________________________________
EXAMPLES:
In ten year’s time you will ________________________________________________________________
______________________________________________________________________________________
This medical condition cannot _____________________________________________________________
______________________________________________________________________________________
You’ll never become a ___________________________________________________________________
______________________________________________________________________________________
Why can’t you be like? ___________________________________________________________________
______________________________________________________________________________________
What will be, will be _____________________________________________________________________
______________________________________________________________________________________
Has there been “expert” diagnosis that you or your family has regarded as now unchangeable? Which was
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
LET THE PATIENT BEWARE:
II. CLINICAL
You can help us save time by explaining in your own words some things about your problem. Please be as specific as possible. A few particular examples of how the problem comes up would be valuable.
A. State in your own words the nature of your chief concern: _____________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
B. If your problem is something that you think happens too often, state approximately how often it occurs, how long it lasts, and any other information you feel might be helpful in understanding your problem._____________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
C. If your problem is concerned with something not happening as often as you would like, state what you would like to see happen more often, how often you think it should occur, etc.
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
D. Are any of the people in Section I, items F and G, important in some way with your problem?
YES _____ NO_____
If yes, please mention specific ways they have helped you - both good and bad points should be mentioned, if possible. _____________________________________________________________________________
_______________________________________________________________________________________
E. With whom have you talked about your problem? ___________________________________________
F. What medications are you taking? _______________________________________________________
III. DEVELOPMENTAL
A. Date and place of birth: _____________________________________________________________
B. Approximately
how many times did your family move when you were young?_____________
Since you left
your parental home?_____________ Your
age when you left? _____________
C. Childhood:
___________________________________________________________________________________
Night terrors; Bed wetting; Sleep-walking; Thumb-sucking; Nail-biting; Stammering; Fears; Happy childhood; Unhappy childhood.
D Health:
How related to your present problem? ____________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
8. When was the last time you felt well, both physically and emotionally for a fair amount of time?
______________________________________________________________________________________
______________________________________________________________________________________
Other _________________________________________________________________________________
IV. VOCATIONAL INTERESTS
A. Game and interests during childhood:
(Including make-believe)
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
B. Interests and hobbies during adolescence:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
C. Any athletic interests and/or accomplishments?
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
D. Present interests, hobbies, activities, organizations:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
E. How is most of your free time occupied?
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
V. EDUCATION:
A. Last grade or year completed: ___________________________________________________________
Degree(s): _______________________________________________________________________
Dates(s)
_________________________________________________________________________
B. Relationship to schoolmates: ____________________________________________________________
C. Scholastic abilities
and disabilities: _______________________________________________________
D, Were you ever bullied,
or given a nick-name? Please explain briefly.
_______________________________________________________________________________________
E. Do you make friends easily?________________Do you keep them? _____________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
VI. OCCUPATION:
A. Age when you started working: __________________________________________________________
B. Jobs held (in chronological order and reasons for
change)
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
C. How long employed in present job? ______________________________________________________
D. Does your present work satisfy you? (If not, in what ways are you dissatisfied?)
_______________________________________________________________________________________
_______________________________________________________________________________________
E. What do you and your spouse earn?
______________________________________________________
F. Ambitions and aspirations: _____________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
VII. SEX INFORMATION
A. Parental attitudes toward sex. (For example, was there sex instruction or discussion in the home?)
______________________________________________________________________________________
______________________________________________________________________________________
B. When and how did you derive your first knowledge of sex? ____________________________________
C. When did you first become aware of your sexual impulses? ____________________________________
______________________________________________________________________________________
D. Did you ever experience any
anxieties or guilt feelings or trauma arising out of masturbation? If yes, please explain.
__________________________________________________________________________
E. Did you ever experience any anxieties or guilt feelings or trauma arising out of sexual experience with the opposite sex? If yes, please explain. _________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
F. Did you ever experience any anxieties or guilt feelings or trauma arising out of sexual experience with the same sex (homosexuality)? If yes, please explain. ______________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
G. Menstrual History: Age at first period ______________
Were you informed, or did it come as a shock? _______________________________________
Are you regular? _______________________ Duration _______________________
Do you have pain? ______________ Does your periods affect your moods? _________________
H. Is there any question or concern you have about sex past/present or future, or sexual identity?
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
VIII. MARITAL HISTORY -Present
Marriage
A. How long did you know your marriage partner before engagement? ___________________________
How long were you engaged? ________________ How long have you been married? _______________
B. Please describe something of what you liked and disliked about your mate: ______________________
_____________________________________________________________________________________
What I liked the first few years:
___________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
What my mate liked the first few years: ______________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
What I disliked the first few years: __________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
What my mate disliked the first few years: ___________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
What I have liked the last few months:
______________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
What I have disliked the last few months: ____________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
What my mate has liked/disliked the last few months: ___________________________________________
_______________________________________________________________________________________
VIII. MARITAL HISTORY (Continued)
C. In what areas are you most compatible?
___________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
D. In what areas is there incompatibility? ___________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
E. How do you get along with your in-laws (This includes brothers-in-law, and sisters-in-law): _________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
F. Give specific examples of those things you would like to see your spouse do more often (e.g. take the garbage out, bring you a cup of coffee when you have just sat down to relax, etc. ): ___________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
G. Give three specific examples of things you would like to see your spouse stop doing. (Three particular things that irritate you.): __________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
H. Please list the names of your children, from the oldest to youngest: (State if any of these children are from a previous marriage, or adopted) (Also, in the birth order, please include any miscarriages, or abortions.) Please give the following information:
|
Name |
Sex |
Age |
Marital Status |
Job |
Describe each person |
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VIII. MARITAL HISTORY-Previous Marriages:
When were you first married and for how long? _______________________________________________
How long did you know your first spouse before engagement? ___________________________________
How long were you engaged? _____________________________________________________________
Please describe something you liked and disliked about your previous
mate:
What I liked:
_____________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
What I disliked:
___________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Please -describe something of what your previous mate liked and disliked about you:
What he/she liked: ________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
IX. FAMILY DATA
|
Name |
Sex |
Age |
Marital Status |
Job |
Describe each person |
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B. Your relation ship with your brothers and
sisters?
(a) Past:
_________________________________________________________________________
______________________________________________________________________________
(b) Present: ______________________________________________________________________
______________________________________________________________________________
C. Brother or sister most like you, in what respect? _____________________________________________
_______________________________________________________________________________________
D. Brother or sister most different from you, in what respect? _____________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
E. Who played together? __________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
F. Any unusual achievements? _____________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
G. Any accidents or illnesses (bumps to head, hospitalizations, etc.)? _______________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
IX. FAMILY DATA (Continued):
H. "Father"
here means the man who took primary responsibility for raising you. If that is
a different person than your biological father, please describe what you know
of your biological father on the back of this page, and describe your father on
this page.
Father’s Name ___________________________________________ Current Age ___________________
Occupation
_____________________________________________ Health:
Good Average Poor
(Circle one)
If deceased, cause of death and age at death: __________________________________________________
Your age at the time ___________________________________________
Kind of person: _________________________________________________________________________
_______________________________________________________________________________________
His ambition for the children: ______________________________________________________________
_______________________________________________________________________________________
His relationship to the children: ____________________________________________________________
_______________________________________________________________________________________
His relationship to the Mother (his wife): _____________________________________________________
_______________________________________________________________________________________
His favorite child, why: ___________________________________________________________________
_______________________________________________________________________________________
Which child was most like Dad, why: ________________________________________________________
_______________________________________________________________________________________
Which child was most different from Dad, why: _______________________________________________
_______________________________________________________________________________________
As a child, what I liked about Dad:
__________________________________________________________
_______________________________________________________________________________________
As a child, what I disliked about Dad:
_______________________________________________________
_______________________________________________________________________________________
IX. FAMILY DATA (Continued)
H. "Mother" here means the woman who took primary responsibility for raising you. If that is a different person than your biological mother, please describe what you know of your biological mother on the back of this page, and describe your mother here.
Occupation
___________________________________________ Health:
Good Average Poor
(Circle one)
If deceased, cause of death and age at death
___________________________________________________
Kind of person: _________________________________________________________________________
_______________________________________________________________________________________
Her ambition for the children:_______________________________________________________________
_______________________________________________________________________________________
Her relationship to the Father (her husband): __________________________________________________
_______________________________________________________________________________________
Her relationship to the children: ____________________________________________________________
_______________________________________________________________________________________
Her favorite child, why: ___________________________________________________________________
_______________________________________________________________________________________
Which child was most like Mom, why: _______________________________________________________
_______________________________________________________________________________________
Which child was most different from Mom, why _______________________________________________
_______________________________________________________________________________________
As a child, what I liked about Mom:
_________________________________________________________
_______________________________________________________________________________________
As a child, what I disliked about Mom: ______________________________________________________
_______________________________________________________________________________________
IX. FAMILY DATA: (Continued)
J. As a child, in what ways were you punished by your parents? ___________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
K. Give an impression of your home atmosphere (i.e., the home in which you grew up). ________________
_______________________________________________________________________________________
_______________________________________________________________________________________
L. Were you able to confide in your parents? __________________________________________________
_______________________________________________________________________________________
M. If you were not brought up by your parents, who did raise you? Between what years? If you were raised by your parents, was there another parental figure? _____________________________________________
_______________________________________________________________________________________
N. Has anyone (parents, relatives, friends) ever interfered in your marriage, occupation, etc.? ____________
_______________________________________________________________________________________
_______________________________________________________________________________________
0. Does any member of your family suffer from alcoholism, drug addiction, or anything which can be considered a "mental disorder"? ____________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
P Are there any other members of the family about whom information regarding illness, etc., is relevant?
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Q. Please try to remember any fearful or distressing experiences not previously mentioned.
_______________________________________________________________________________________
_______________________________________________________________________________________
X. SELF DESCRIPTION
A. In what kinds of situations do you most readily lose self-control? (Cite particular instances if at all possible. Examples might be temper, uncontrollable crying, impatience, etc.):
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
B. In which situations are you best able to maintain self-control?: _________________________________
_______________________________________________________________________________________
C. Give a word picture (description) of yourself, as you would be described by:
1. Your
spouse:
___________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
2.Your best friend:
_________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
3. Your worst enemy: ______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
4. Yourself: ______________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Complete the following sentences:
-As a child, I
__________________________________________________________________________
______________________________________________________________________________________
-For me, school was:
____________________________________________________________________
______________________________________________________________________________________
-My childhood fears were
________________________________________________________________
______________________________________________________________________________________
-.My childhood ambitions
were:
___________________________________________________________
______________________________________________________________________________________
.My role in my group of
friends was: _______________________________________________________
-The significant events in my
physical and sexual development were:
_____________________________
______________________________________________________________________________________
- My social development
was:
_____________________________________________________________
_______________________________________________________________________________________
-The most important values in
my family were:
________________________________________________
_______________________________________________________________________________________
-What stands out the most for
me about my family life is:
________________________________________
_______________________________________________________________________________________
-My parents' relationship to
each other was:
___________________________________________________
_______________________________________________________________________________________
-Brothers' and sisters'
relationship to Dad was:
_________________________________________________
_______________________________________________________________________________________
-Brothers' and sisters'
relationship to Mother was:
______________________________________________
-My parents' relationship to
us children was:
__________________________________________________
______________________________________________________________________________________
BLESSINGS NOT GIVEN TO US
Look at the
ways that children are wounded on both worksheets; Blessings Not Given and
Hurtful Things Done To Us. Use a check mark in the left-hand column under D for
Dad and M for Mom to identify where you experienced similar wounding. In the
right-hand column under 1, where you have wounded others and under 2 where you
are still receiving wounding.
D |
M |
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1 |
2 |
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Did
not seek what was best for the children, and giving that, even when it meant
sacrificing their needs. |
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Did
not speak words of affirmation, praise, encourage, blessing and value. |
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Did
not give affectionate touch freely and often. |
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Did
not approach life as an adventure. |
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Did
not teach Beauty, Music Art, Nature. |
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Did
not have regular family gatherings. |
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Did
not appropriate discipline. |
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Did
not communicate; speaking in ways that are understandable and consistent. |
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Did
not make themselves known and share their hearts in appropriate ways. |
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Lack
of light heartedness; laughter, fun, tickles, wrestling, humor. |
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Lack
of security; a home that was not physically, emotionally and spiritually
safe. |
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Not
valuing us and relationship more than family image or money or addictions. |
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Not
working and playing together. |
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Did
not say “Forgive Me”. |
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Did
not say “I Love You”. |
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Did
not make times a celebration. |
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Not
doing things just for fun. |
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Lack
of flexibility. |
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Living in The Kingdom |
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Did
not teach us how to worship in church. |
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Did
not teach us how to worship and dance at home. |
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Did
not read and teach the Scriptures. |
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Did
not have bedtime prayer. |
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Did
not pray to and speak of |
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Did
not give thanksgiving at meals. |
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Did
not model forgiveness. |
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Did
not pray and speak blessing over our lives and the lives of others including
those people considered enemies. |
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Teaching and Modeling |
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Did
not teach us how to trust in God during crisis. |
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Did
not teach us how to communicate and share our hearts. |
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Did
not teach us w to resolve conflict together as a family. |
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Did
not teach us how to be a husband or wife. |
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Did
not teach us how to handle money. |
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Did
not teach us about sexuality. |
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HURTFUL THINGS DONE TO US
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D |
M |
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1 |
2 |
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Father absent (physically or emotionally) |
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Mother absent (physically or emotionally |
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Not defended |
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Abandoned or rejected ( physically, emotionally or verbally) |
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Parents not wanting child. |
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Not wanting child of your sex. |
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Wanting a child for selfish reasons (e.g. to save marriage or find purpose) |
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A parent being the reason that home was an insecure or unsafe place |
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Blaming |
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Not being allowed to speak. |
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Parent(s) being closed off to closeness, unwilling to make themselves known. |
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Parent(s) sharing things that were inappropriate or burdensome for child. |
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Overly serious about life. |
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Inflexible/rigid parenting. |
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Religiousness. |
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Control |
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Manipulation. |
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Acceptance conditional or not at all. |
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Made to be responsible for parents emotional well being or for sibling. |
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Abuse |
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Verbal |
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