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 in blanks)
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? ________________________________________________
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MY GOALS ARE:  (Please give immediate, short term, and long turn goals).  ________________
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What do you expect to receive from the Whole Person Counseling Resident Training? __________
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How do you see the Resident Training benefiting your goals?  ____________________________
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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 ____________________________________________________________________
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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 _____________________.

Thanks,
Basil Frasure, Ph.D.