PRAYER MINISTRY INTAKE FORM

STRICTLY CONFIDENTIAL

EYES ONLY

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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. )

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G. List 3 people not mentioned in F above who are important to you - people who are

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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

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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