Denomination preference: _________________________ Member of ________Church
Church attendance per month (circle): 0 1 2 3 4 5 6 7 8 9 10+
Church attended in childhood: ___________________ Baptized? Yes ________ No____
Religious Background of spouse (if married): ___________________________
Baptized? Yes___ No____
Do you consider yourself a religious person? Yes _______ No _______ Uncertain _______
Do you believe in God? Yes _____ No _______ Uncertain_________
Do you believe Satan exists? Yes________ No_____________ Uncertain_______________
Have you ever “dabbled” with the “Occult” – Séances, devil worship, witchcraft? Yes______ No__________ Uncertain____________
Do you pray to God? Never_______ Occasionally ________ Often_________
Would you say you are a Christian? Yes_____ No___________ or would you say you are still in the process of becoming a Christian?_______________________
How often do you read the Bible? Never______ Occasionally ________ Often ______________
Do you have regular devotions? Yes ___________ No______ Not sure what you mean__________
Explain recent changes in your religious life, if any _______________________________________
Other ____________________________________________________________
FAMILY AND CHILDHOOD INFORMATION:
If you were reared by anyone other than your own parents, briefly explain: __________________________________________________________________________
How many older brothers _____ sisters _____ do you have?
How many younger brothers _____ sisters _____ do you have?
Are you on good terms with your Mother _____ Father _____ Brother _____ Sisters? _____
List the people that you hate or are extremely angry with, and the reasons: ____________________________________________________________________________
Self-disciple Whiner Selfish Lots of friends Failure Success
Other ______________________________
Where did you grow up? _____ Urban Area _____ Suburban Area _____ Small Town _____ Rural _____ Farm City, State _____________________________ Population ________________________
What was your family’s economic situation when you were a child?
_____ Extremely poor _____ Poor _____Lower Middle Income _____ Middle Income _____Higher Middle Income _____Wealthy _____ Extremely wealthy
Were you ever sexually abused by anyone? _____ No _____ Yes
(Please detail: _____ Were you abused by a relative? _____ Were you abused by a stranger? _____ A neighbor? How old were you at the time? _____ Was the person who abused you ever prosecuted? ______)
What was your happiest memory as a child? _____________________________________________________________________________
Have you ever felt people were watching you? Yes _____ No _______
Have you ever felt people were watching you? Yes ______ No _______
Do people’s faces ever seem distorted? Yes_______ No _______
Do you ever have difficulty distinguishing faces? Yes _______ No ______
Do colors seem too bright? ______ Too dull? _________
Are you sometimes unable to judge distance? Yes_____ No______
Have you ever had hallucinations? Yes_______ No_______
Are you afraid of being in a car? Yes _____ No _____
Is your hearing exceptionally good? Yes______ No________
Do you have problems sleeping? Yes______ No________
PERSONAL BEHAVIORAL HABITS
Do you think coffee or other caffenated drinks? Yes _____ No _____ How much per day?
Do you smoke? Yes _____ No _____ How much? ____________________________
Do you explode when you get angry? Yes _____ No _____
Do you withdraw when you get angry or hurt? Yes _____ No _____
Do you frequently argue with significant other people? Yes _____ No _____
WOMEN ONLY
Have you had any menstrual difficulties? ______________________________________________
Do you experience tension, tendency to cry, other symptoms prior to your cycle? Please explain: ________________________________________________________________________________