PRAYER MINISTRY INTAKE FORM

 

 

 

 

 

 

 

 

STRICTLY CONFIDENTIAL

 

 

 

 

 

 

 

 

EYES ONLY

 

                                    ___________________________________________

 

                                    ___________________________________________

 

                                    ___________________________________________

 

                                    ___________________________________________

 

                                    ___________________________________________

 

 

 

 

 

 

 


ST. JAMES THE LESS CHURCH                                                                  October 2, 2002

 

A LIFE HISTORY OUESTIONNAIRE

 

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 __________________

 

C. Age ___________________   D. Occupation ____________________________

 

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 INVENTORY

 

SESSION NINE

 

Before you start this step to freedom and wholeness in Christ, you need to renounce all activity you have been involved in that would encompass false religion, occult or satanically inspired practices.  The following list is not comprehensive.  It gives an indication of some of the areas in each section where Christians may have come into bondage.  There may well be other occult or psychic activities not included that may be equally harmful that you are aware of.  Please indicate your involvement under “other”.  Mark this list by ticking in the appropriate box if you, your spouse or your family have been involved in the areas.

 

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                                                                        

Edgar Cayce                                                                                      Ouija Board                                                                         

Horoscopes                                                                                      Palm Reading                                                                      

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                                                                                    

 

 

 

PSYCHIC RITES, SERVICES AND ACTIVITIES:

 

(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)                                                   

Crystals                                                                                             Magnetic Healing                                                                              

 

Pyramids                                                                                           

Radionics                                                                            

 

 

 

 

 

 

 

27 1 Samuel 15:22, 23 But Samuel replied:  “Does the Lord delight in burnt offerings and sacrifices as much as in obeying the voice of the Lord?  To obey is better than sacrifice, and to heed is better than the fat of rams.  23 For rebellion is like the sin of divination, and arrogance like the evil of idolatry.  Because you have rejected the word of the Lord, he has rejected you as king.”

 

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).

 

 

 

NEW AGE MOVEMENT

 

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                                                                                             St. Christopher                                                                   

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 Columbus                                                                      Shriners                                                                               

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                                                                       

Baha’ism                                                                                            Shintoism                                                                            

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 Satan                                                                  

Deity of Jesus                                                                                   Reality of Sin                                                                      

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:

 

  1. Beware of therapies that are energy based and claim to manipulate “invisible energies” or rely on psychic anatomies.

 

  1. Beware of those who utilize psychic knowledge, power or abilities.

 

  1. Beware of a practitioner who has a therapy that almost no one else knows of.

 

  1. Beware of any technique that is promoted to the general public before it has been validated by mainstream science.

 

  1. Beware of anyone claiming that his therapy will cure almost anything, as in some kinds of chiropractic, color therapy, acupuncture, and homeopathy.

 

  1. Beware of someone whose explanations are bizarre or don’t make sense.

 

  1. Beware of therapies whose primary proof is found in the testimonies of satisfied clients.

 

  1. Beware of therapies that rely upon entering altered states of consciousness, such as hypnotic regression, meditation and many visualization programs.

 

  1. Realize that a practitioner’s sincerity is no guarantee of scientific or medical legitimacy.

 

 


 

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 INFORMA TION

 

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:

 

  1. Mother's condition during pregnancy (as far as you know)

 

___________________________________________________________________________________

 

  1. Underline any of the following that apply during your childhood:

 

Night terrors; Bed wetting; Sleep-walking; Thumb-sucking; Nail-biting; Stammering; Fears; Happy childhood; Unhappy childhood.

 

D         Health:

 

  1. Health during childhood:____________________________________________________________

 

  1. List childhood illnesses: ____________________________________________________________

 

  1. Health during adolescence: __________________________________________________________

 

  1. List adolescent illnesses: ____________________________________________________________

 

  1. Any physical disabilities? ___________________________________________________________

 

How related to your present problem?  ____________________________________________________

 

______________________________________________________________________________________

 

  1. Your present height:  ________________________________  Weight:  ______________________

 

 

  1. Any surgical operations? Please list them, and at what age they occurred.

 

______________________________________________________________________________________

 

______________________________________________________________________________________

 

8.      When was the last time you felt well, both physically and emotionally for a fair amount of time?

 

______________________________________________________________________________________

 

______________________________________________________________________________________

 

  1. Underline any of the following that apply to you: Headaches; Dizziness; Fainting spells; Palpitations; Stomach trouble; No appetite; Bowel disturbances; Fatigue; Insomnia; Nightmares; Take Sedatives; Alcoholism; Feel tense, Feel panic; Tremors; Depressed; Suicidal ideas; Drugs; Unable to relax; Sexual problems; Unable to have a good time; Don't like weekends and vacations; over- ambitious; Shy with people; Can't make friends; Feel lonely; Can't make decisions; Can't keep a job; Inferiority feelings; Home conditions bad; Financial problems.

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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:  ________________________________________________________________

 

            ________________________________________________________________________________

 

            ________________________________________________________________________________

 

            ________________________________________________________________________________

 

            ________________________________________________________________________________

 

What he/she disliked  _______________________________________________________________

 

            _________________________________________________________________________________

 

            _________________________________________________________________________________

 

            _________________________________________________________________________________

 

IX. FAMILY DATA

 

  1. List all brothers and sisters from oldest to youngest, including yourself. Please list in birth order, including any miscarriages, or abortions that you know of.

 

Name

Sex

Age

Marital Status

Job

Describe each person

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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.

 

Mother’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:  _________________________________________________________________________

 

_______________________________________________________________________________________

 

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:  ______________________________________________________________________

 

______________________________________________________________________________________

 

______________________________________________________________________________________

FAMILY DATA

 

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

 

1

2

 

 

Did not seek what was best for the children, and giving that, even when it meant sacrificing their needs.

 

 

 

 

Did not speak words of affirmation, praise, encourage, blessing and value.

 

 

 

 

Did not give affectionate touch freely and often.

 

 

 

 

Did not approach life as an adventure.

 

 

 

 

Did not teach Beauty, Music Art, Nature.

 

 

 

 

Did not have regular family gatherings.

 

 

 

 

Did not appropriate discipline.

 

 

 

 

Did not communicate; speaking in ways that are understandable and consistent.

 

 

 

 

Did not make themselves known and share their hearts in appropriate ways.

 

 

 

 

Lack of light heartedness; laughter, fun, tickles, wrestling, humor.

 

 

 

 

Lack of security; a home that was not physically, emotionally and spiritually safe.

 

 

 

 

Not valuing us and relationship more than family image or money or addictions.

 

 

 

 

Not working and playing together.

 

 

 

 

Did not say “Forgive Me”.

 

 

 

 

Did not say “I Love You”.

 

 

 

 

Did not make times a celebration.

 

 

 

 

Not doing things just for fun.

 

 

 

 

Lack of flexibility.

 

 

 

 

Living in The Kingdom

 

 

 

 

Did not teach us how to worship in church.

 

 

 

 

Did not teach us how to worship and dance at home.

 

 

 

 

Did not read and teach the Scriptures.

 

 

 

 

Did not have bedtime prayer.

 

 

 

 

Did not pray to and speak of Jesus as part of everyday.

 

 

 

 

Did not give thanksgiving at meals.

 

 

 

 

Did not model forgiveness.

 

 

 

 

Did not pray and speak blessing over our lives and the lives of others including those people considered enemies.

 

 

 

 

Teaching and Modeling

 

 

 

 

Did not teach us how to trust in God during crisis.

 

 

 

 

Did not teach us how to communicate and share our hearts.

 

 

 

 

Did not teach us w to resolve conflict together as a family.

 

 

 

 

Did not teach us how to be a husband or wife.

 

 

 

 

Did not teach us how to handle money.

 

 

 

 

Did not teach us about sexuality.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HURTFUL THINGS DONE TO US

 

D

M

 

1

2

 

 

Father absent (physically or emotionally)

 

 

 

 

Mother absent (physically or emotionally

 

 

 

 

Not defended

 

 

 

 

Abandoned or rejected ( physically, emotionally or verbally)

 

 

 

 

Parents not wanting child.

 

 

 

 

Not wanting child of your sex.

 

 

 

 

Wanting a child for selfish reasons (e.g. to save marriage or find purpose)

 

 

 

 

A parent being the reason that home was an insecure or unsafe place

 

 

 

 

Blaming

 

 

 

 

Not being allowed to speak.

 

 

 

 

Parent(s) being closed off to closeness, unwilling to make themselves known.

 

 

 

 

Parent(s) sharing things that were inappropriate or burdensome for child.

 

 

 

 

Overly serious about life.

 

 

 

 

Inflexible/rigid parenting.

 

 

 

 

Religiousness.

 

 

 

 

Control

 

 

 

 

Manipulation.

 

 

 

 

Acceptance conditional or not at all.

 

 

 

 

Made to be responsible for parents emotional well being or for sibling.

 

 

 

 

Abuse

 

 

 

 

Verbal