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. )

_______________________________________________________________________________________

 

_______________________________________________________________________________________

 

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