PERSONAL INFORMATION

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Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Sex {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Present Marital Status {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Have you been divorced? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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FAMILY HISTORY

Are you adopted? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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In what kinod of home structure were you rasied? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Are your parents still living? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Are they presently married or divorced? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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To Your Knowledge, Is There a Family History Of:

For each area, indicate yes or no, then who in your family were involved.

Adultery {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Divorce {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Incest {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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--------------------------------------------------------------------------------------------------- {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Drug Abuse {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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--------------------------------------------------------------------------------------------------- {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Alcoholism {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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--------------------------------------------------------------------------------------------------- {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Mental Illness {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Depression {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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--------------------------------------------------------------------------------------------------- {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Suicide {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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--------------------------------------------------------------------------------------------------- {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Are there any addictive problems in your family history? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Do you have any addictions or cravings that you find difficult to control? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Moral Climate

During the first 18 years of your life, how would you rate the moral atmosphere in which you were raised

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Overly PermissivePermissiveAverageStrictOverly Strict
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Stages in Life

In each of the following stages of your life, give 2-3 adjectives that describe your life during those years. Explain why you felt that way or what caused those feelings during that time of your life. Write "can't remember" if you have no memories of that time period. Write NIA if you have not reached that age range yet.

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Think about your childhood. What did you come to believe about yourself, based on things that were said and done (or not said and done) to you by the significant people in your life? (e.g. you are shameful, not worthy loving, a failure, must earn love, etc.)

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What were some "family secrets" that everyone in your childhood family kept hidden?

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How did you protect yourself or make yourself feel significant during your growing up years? Were the things you tried successful?

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How are you protecting yourself or making yourself feel significant today?

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PERSONAL HEALTH HISTORY

Physical Health

Are you presently using any kind of medication for either physical or psychological reasons? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Have you sought help from a counselor or therapist? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Do you have problems sleeping? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Are you having recurring nightmares or disturbances? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Does your present schedule allow for regular periods of rest, relaxation and recreation? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Have you ever been physically beaten or sexually molested? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Mental Health

Which of the following are you currently struggling with? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Do you find prayer difficult? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Emotional Health

Which of the following emotions are you presently having difficulty controlling? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Fear is a common emotion that is often not recognized or acknowledged. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Please check any of the above fears you are currently experiencing.

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SPIRITUAL HISTORY

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Select one option from the pulldown -->

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Salvation and Fellowship

1 John 5:11,12 says, "God has given us eternal life, and this life is in His Son. He who has the Son has the life; he who does not have the Son of God does not have the life:'

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Are you plagued with doubts concerning your salvation? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Are you under authority to a local Bible teaching church? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Do you support your church with your time, talent, & finances? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Was there anything not covered in this Inventory you feel we should know about? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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PERSONAL INFORMATION

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Age {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Sex {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Present Marital Status {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Have you been divorced? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Present Vocation (where employed, for what job and when) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Most Recent Past Vocation {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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How did you find out about Freedom in Christ and this Community Freedom Ministry? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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FAMILY HISTORY

Are you adopted? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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If yes, what do you know about your birth parents? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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In what kinod of home structure were you rasied? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Are your parents still living? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Are they presently married or divorced? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Briefly explain your parents' Christian experience (i.e.,Did they profess and live their Christianity?) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Was there a sense of security and harmony during the first 12 years of your life? Explain. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Was the father clearly the head of the home or was there a role reversal where the mother ruled the home? Explain. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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How did your father treat your mother? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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List the name of individuals who had significant influence on your life. Explain briefly why their influence was significant. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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To Your Knowledge, Is There a Family History Of:

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Divorce {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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--------------------------------------------------------------------------------------------------- {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Incest {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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--------------------------------------------------------------------------------------------------- {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Drug Abuse {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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--------------------------------------------------------------------------------------------------- {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Alcoholism {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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--------------------------------------------------------------------------------------------------- {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Mental Illness {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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--------------------------------------------------------------------------------------------------- {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Depression {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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--------------------------------------------------------------------------------------------------- {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Suicide {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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--------------------------------------------------------------------------------------------------- {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Are there any addictive problems in your family history? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Please explain: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Do you have any addictions or cravings that you find difficult to control? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Moral Climate
During the first 18 years of your life, how would you rate the moral atmosphere in which you were raised {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Stages in Life

Preschool Years {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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K thru Grade 2 Years {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Grade 3 thru Grade 6 Years {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Childhood Influencers {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Jr High (or Middle School) Years {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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High School Years {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Family Secrets {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Childhood Self Significance {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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20's {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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30's {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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40's {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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50's {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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60's and Older {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Adult Self Significance {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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PERSONAL HEALTH HISTORY

Physical Health

Are you presently using any kind of medication for either physical or psychological reasons? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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What medications and for what reason? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Have you sought help from a counselor or therapist? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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How long have you been under care and how often? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Do you have problems sleeping? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Please explain: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Are you having recurring nightmares or disturbances? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Please explain: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Does your present schedule allow for regular periods of rest, relaxation and recreation? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Have you ever been physically beaten or sexually molested? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Please Explain {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Mental Health

Which of the following are you currently struggling with? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Do you spend much time wishing you were somebody else or in a different time, place or circumstance? Explain. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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What areas of life have you tried the same things over and over with frustrating results? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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What are some habits, compulsions, and sins over which you feel you have no control? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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What are some feelings of failure and frustration you have been unwilling or unable to share with your loved ones? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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How many hours per week do you watch TV? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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What are your favorite shows or movie themes? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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How many hours per week do you listen to music? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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What types of music? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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How many hours per week are spent reading? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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What types of books? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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How many hours per week are spent on social media? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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What types of social media and percent of total time? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Do you have regular devotions in the Bible? Describe what you do during your personal devotions? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Do you find prayer difficult? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Please explain: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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At church or other Christian meetings, are you plagued with foul thoughts, jealousies, or other harassments? Explain {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Emotional Health

Which of the following emotions are you presently having difficulty controlling? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Which of the above listed emotions do you feel are sinful? Why? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Fear is a common emotion that is often not recognized or acknowledged. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Concerning your emotions (whether positive or negative) which of the following best describes you? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Who in your life can you be emotionally honest with? (i.e., you can tell this person exactly how you feel) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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How important is it that we are emotionally honest before God and do you feel that you are? Explain: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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SPIRITUAL HISTORY

If you were to die today how certain are you that you would go to heaven? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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If you died and God were to ask you, "Why should I allow you into My heaven?" how would you answer Him. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Salvation and Fellowship

Does the Son of God live in you? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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If so, when did you receive Him? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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How do you know that you have received Him? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Are you plagued with doubts concerning your salvation? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Please describe your doubts: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Are you presently enjoying fellowship with other believers? If so, where and when? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Are you under authority to a local Bible teaching church? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Name and city location of Church: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Please Explain Why Not: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Do you support your church with your time, talent, & finances? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Please Explain Why Not: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Was there anything not covered in this Inventory you feel we should know about? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Please explain: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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