Please copy the template below into Notepad. Save the file on your hard drive and fill in your answers.
When you are done, copy and paste it into an email and send it to Gladys Raj.
QUESTIONNAIRE FOR HEALING OF THE WOUNDED SOUL THROUGH THE MINISTRY
OF THE WORD OF GOD, THE HOLY SPIRIT, AND PRAYER
1. Your Name:
4. Email Address:
6. Date of birth: mm/dd/yyyy
9. Were you raised by anyone other than your parents? (Briefly explain):
10. How many older brothers ___ sisters ___ do you have?
11. How many younger brothers ___ sisters ___ do you have?
12. Did you have both the parents/stepparents or were you adopted? Explain:
13. Are your parents presently married? Alive or deceased? Explain:
14. Was there a sense of security and harmony in your
home during the first twelve years of your life?
15. How was authority exercised in the home?
Which parent was in charge and how did he or she operate?
16. How was affection shown between your parents and toward you?
17. Where did you feel most safe in growing up?
18. Was there a safe place at home?
19. Are you aware of any adultery, incest, and/or sexual abuse
in your family or that of your grandparents? Explain.
20. Have any of your parents, grandparents or great-grandparents to your knowledge ever
been involved in any occultic, cultic or non-Christian religious practices? Explain:
21. Briefly explain your parents’ belief and faith:
22. Any addictions in your family (e.g. alcohol, drugs, gambling, pornography, etc.) ?
23. Any history of mental or genetic illness?
24. Any history of suicide in the family?
25. Any recent deaths in family, close friends or important person in your life?
26. Any history of accidents, or murder, crime, or violence in the family?
[DESCRIBE YOUR PERSONALITY]
27. Please indicate how much each word describes you by inserting
a number next to each word.
1 = NOT TRUE 10 = VERY TRUE
28. Education (Highest grade completed):
29. Talk about your relationship with your school mates:
30. How did you get along with your teachers?
31. If you had trouble with school mates, or teachers what age it began?
[PERSONAL PHYSICAL AND EMOTIONAL INFORMATION]
32. List all crucial present or past illnesses or injuries.
33. Are you presently taking medication? Yes/No If yes, what medication?
34. Do you have or have you had any addictions to alcohol, drugs, etc.?
35. Age when using alcohol:
36. Age at first use of drugs:
37. Drug or Drugs used: How used? How long?
38. Age when involved:
39. Have you ever had or have a severe emotional upset?
Put an "X" next to the word that applies, or explain in more detail.
Suicidal or criminal thoughts
40. Are you happy with your sex?
41. Are you happy with your looks?
42. Do you (have you) desire(d) to be someone else or to live in another place?
43. Check and explain any of the following with which you are having or have had a problem:
44. Describe the way in which you handle positive and negative emotions:
A. Readily express all emotions
B. Express some of my emotions but not all
C. Acknowledge their presence but reserved
D. Tend to suppress my emotions
E. Tend to disregard how I feel
F. Find it safest not to express
G. Tend to consciously or subconsciously deny them since
it is too painful to deal with some of them
45. Is there anyone you can tell exactly how you feel about
yourself and other people?
46. Are you emotionally honest with God? Yes/No
47. Have you ever been in trouble with the law? Yes/No
48. Church attended in childhood:
49. Do you believe in God? Yes/No/Uncertain
50. Do you pray to God? Yes/No/Uncertain
51. What church do you attend now?
52. Are you sure of your salvation?
53. Do you believe in the Bible?
54. How much do you read the Bible and do you understand?
55. How much time do you spend in praying?
56. Do you find praying difficult? Explain:
57. Do you have personal devotion? Yes/No
58. Do you have regular family devotions? Yes/No
59. When attending Christian meetings are you plagued with
foul thoughts, jealousies, or other mental harassment? Explain:
60. Have you had any religious experience? If so, explain.
61. Do you consider yourself a religious person? Yes/No/Uncertain
62. What is your denominational preference, if any?
63. If you were to die right now, do you know for certain
that you would go to heaven?
64. Have any of your family members involved in any cultic or
non-Christian religious practices? (Indicate briefly the involvement):
65. Have you involved in any of the following Non-Christian religion or occult:
Speaking in trance:
Science of mind:
Fortune Telling (Tarot cards, palm reading, etc.) :
Rod & Pendulum (dowsing):
Silva Mind Control:
Magic (black or white):
Children of God:
Worldwide Church of God (Armstrong):
Speaking in trance:
Science of the Creative Intelligence:
66. Have you ever experienced hearing voices? Describe any other
experiences you may have had that would be considered out of the ordinary.
67. Age of first sexual activity:
68. Any sexually transmitted diseases?
69. Sexual problems because of alcohol/drugs?
70. Hetero, homo or bisexual experience:
71. Any extra marital relationship or sexual abuse:
73. Periods of marriage:
74. Belief system of your spouse:
75. If divorced, how was (is that)?
INFORMATION ABOUT CHILDREN
76. How many children do you have?
77. Ages and gender:
78. Have you had miscarriages/abortions?
79. Describe your development during the infancy stage. (You may want to
discuss this with your parents). Were there any unusual circumstances
surrounding your birth and infancy, such as illness, separation from
parents, crises in the home. If so, how do you think these circumstances
may have affected your development?
80. Describe your childhood. Describe your relationship with your parents,
your siblings, and other close relatives.
81. What is your earliest childhood memory?
82. What are the saddest memories of your childhood? What are the happiest memories?
83. Describe your personality as an adolescent and a teenager. How did your
relationships with your parents change during this time?
84. Did you have many close friends during this stage of life?
85. How did your friends influence you?
86. What are the saddest memories of your teenage years? What are the happiest memories?
87. Are you struggling with blame, guilt, regret and disappointment?
88. Are you struggling with submission and pride?
89. You may have been the victim? Have you been harboring hate, resentment,
bitterness, and unforgiveness?
90. Describe how your past is affecting your present.
Multicultural Global Ministry is not professional counseling. It is not licensed or insured as such. It is a prayer ministry. It is the ministry bringing healing through prayer, the power of the Holy Spirit and by the authority of the Word of God. We do not charge for our services.
It is the ministry to help those who are emotionally struggling and seeking freedom. Our dependence is totally upon the power of God through His Word, expecting that He will use us to help you, but we cannot promise results. We can only promise that we will do our best to work with God for your good and God’s glory.
We are not here to replace or negate your seeking the help from a professional counselor. Often it is advisable for a person to receive help from a professional counselor, as well. It is always advisable for the person to actively pursue spiritual disciplines such as church attendance, prayer, Bible study and worship alone with the ministry.
We are committed to keep confidential whatever you share with us. We are, however, required by law to report to appropriate person’s two kinds of things:
1. Any intent of a person to take harmful, dangerous, or criminal action against another person or against him/herself, or
2. Any act of child or elder abuse or neglect.
If it appears that such notification needs to be given, that intention will be shared with you first.
In summary, we would like you to:
1. Understand and agree to the above.
2. Be expectant but not get upset or angry if all that you expect does not happen quickly.
3. Be patient with yourself, with us, and with God.
4. Be prayerful and open for growth and change under the guidance of the Holy Spirit.
5. Engage your will to work with the Holy Spirit and us to move toward what God wants for you.
6. Forgive us if we make mistakes; forgive yourself if you make mistakes; and forgive God if He doesn’t do things the way you expect them to be done.
(type your name here)