PHYSICAL: (Please complete by checking or filling in the blanks) Do you have any physical difficulties? Yes ___ No ___. Please list any difficulties ________________________________ ______________________________________________. Have you had any recent changes: in weight ____ sleep ____ diet ____ rest _____. Are you currently taking any medications? Yes ___ No ___. Please list __________________________________________________________ ___________________________. Have you ever used drugs, tobacco, or alcohol? Yes ___ No ___. Any current use? _______ If yes, what? _____________________________________.
MENTAL/EMOTIONAL: (Please complete by circling, checking or filling
I am often or often feel . . . Absent minded, Forgetful, Confused, Frustrated, Fearful, Lonely, Depressed, Angry, Bitter, Jealous, Ashamed, Guilty, Worthless, Suicidal, Anxious, Worried, Tired, Sad, Hopeless, Hurt, Rejected, other feelings ______________________. Do you have nightmares? Yes ___, No ___. Do you have uncontrolled thoughts? Yes ___ No ___. If so, please explain ____________________________________________. Is there anyone that is holding a grudge against you? _____. If so, have you asked their forgiveness? _____. Is there anyone who has hurt you that you have not forgiven? ______. Is there something important that you would like to change about yourself? _____ What ?_______________________________ ________________. My greatest hurt or disappointment has been _______________________ _______________________________________________. The thing that makes me the most angry is ________________________________________________. I become very depressed when _______________________________________________________. I feel guilty about _______________________________________________________________________.
SPIRITUAL: Are you a member of a local church? ______ Church name _______________ ____________________________. How often do you attend? _____________________. What is the name of your minister? ________________________. Do you consider yourself a Christian? Yes ___, No ___. Is your spouse a Christian? Yes ___ No ___. How often do you read the Bible? Daily ____ Weekly ____ Seldom _____. How do you expect to get to Heaven when you die? __________________ ________________________________. Have you been baptized in water as a demonstration of your faith? Yes ___, No ___. Have you been baptized in the Holy Spirit since you became a Believer? ______. Have you prayed about your situation? Yes ___, No ___. Have you received counsel from anyone that is in authority over you? Parent ___, Pastor ___, Employer ___, or other ________. What? _______________________________ ________________________________. Have you made a commitment to God that you have not kept? _____. Has God told you to do something that you have not done? _____. Do you have any known sins that you have not confessed to God? _____. Do you feel that God has forgiven you? _____.
SOCIAL: (Please underline appropriate answers)
1. I believe most people . . . a. Like me. b. Dislike me. c. Reject me. d. Are indifferent to me.
2. My relationship with my father was/is . . . a. Good. b. Fair. c. Abusive. d. None.
3. My relationship with my mother was/is . . . a. Good. b. Fair. c. Abusive. d. None.
4. For me . . . a. It is difficult to make friends. b. It is easy to make friends.
5. I find myself being . . . a. Passive b. Aggressive c. Assertive . . . toward others.
6. I believe that most people . . . a. Understand me. b. Don't understand me.
7. I find myself . . . a. Accepting most people. b. Being critical of most people.
8. Others would describe me as ________________________________________________.
9. I would describe myself as ____________________________________________________.
HISTORY: Has your parents had any physical, mental or emotional, or spiritual difficulties? _____ If so, please explain ___________________________________________________________ _______________________. Has your parents ever been involved in any of the following: (please underline) 1. Fortune telling (palm reading, tarot cards, tea leaves, crystal ball, Ouija board, astrology, or other). 2. Studied or been a member of an Eastern religion (other than Christianity). If so, what _________________ 3. Studied or been a member of a Christian Cult (Mormon, Jehovah Witnesses, Worldwide Church of God). 4. Have your parents studied or been (in any way) involved in witchcraft (white or black magic) or Satanism? _____ If so, what ____________ ______________________________. What was/is the spiritual beliefs of your parents _______ ___________________________________________________________________________
PERSONAL CONTACT: Do your have any books, music or artifacts associated with the worship of false religions? _____. Have you been a part of or done any extensive studies of false religions? _______ If so, what? ________________ _______________________ Have you been in any way involved in the occult? _____ If so, what ? ______________________________ Do you have or have you listened to Rock music (Christian or otherwise)? _____ Have you allowed yourself to be hypnotized or put in a trance or used channeling? If so, what _________________ _______________________.
PREVIOUS COUNSELING: Have you had previous psychological or psychiatric care? ______ When? ___________ With whom? __________________________________ List any diagnoses given _____________________________________________ You were referred to W.P.C. by _________________________________________.
COUNSELING EXPERIENCE: Have you had any experience in counseling
others? ____ If yes, when? ____________________ In what position
or capacity? ___________________________ ____________________________________________
What kind of cases did you work with? ___________________________________________________________________________
What approach or model did you use in counseling? ____________________________________
What kind of results did you have? ________________________________________________
MY GOALS ARE: (Please give immediate, short term, and long turn
What do you expect to receive from the Whole Person Counseling Resident Training? __________
How do you see the Resident Training benefiting your goals? ____________________________
Have you prayed and found peace about coming for Whole Person Counseling Resident Training?
__________ Have you sought appropriate counsel from others (Pastor, spouse, or close friend) about coming for Resident Training? _______ Were their responses positive? ______ Please explain ____________________________________________________________________
DATES SELECTED: (See: http://www.wholeperson-counseling.org/ndoc2/schedule-o.html
for Schedule Openings) I recommend the two weeks of training (1/2
day each day Monday through Friday) although I may consider doing it in
a one week (40 hour) period). Please select a first choice of dates
(example: December 2-13 ) and a second choice if the first choice is unavailable.
My first choice is ______________________ My second choice is _____________________.
Basil Frasure, Ph.D.