Need Ministry - Review Form

Male
Female
Home Phone
Cell Phone
German
Indian
Irish
English
Hispanic
Oriental
Middle East
Jewish
Scottish
French
Irish
Polish
Canadian
Italian
African - Nigarian
Filipino
Other
Yes Seeing Counselor or Minister
No Not Seeing Counselor or Minister
Murder
Incest
Pedophilia
Street Drug Addiction
Alcoholic Problem
Bankruptcy
Mental Health Issues
Commited Suicide or Atempted Suicide
Depression and on Medication
Unusual Fears
Superstition
Jail/Prison
Pornography
Eating Disorders
Sold Drugs
Divorce
Moved a lot
Blended Family
Father / Mother left
N/A
When I see the person that hurt me I feel resentment
I intentionally turn away to ignore and avoid him or her
When someone mentions his or her name it leave a “bitter taste in your mouth"
Just thinking about him or her “make you sick”–give me a bitter stomach
I have a similar negative reaction when I just hear his or her name mentioned
When I think of the person, I feel offended
I resent his or her success–hearing any good report about him or her
I secretly desire misfortune or failure–or worse–to come his or her life
I mentally argue with them–i.e. dream or daydream about “putting him or her in their place”
I feel the need or see a tendency to talk to others about the failures or shortcomings of those who have hurt or offended me
I complain A LOT, sometimes about the same things
I feel separated from God even when I pray
I condemn people
I am judgmental and accuse
I am easily offended
I gossip and say innuendos
I keep a record of wrong
I feel misunderstood
I have racism
I cause division and argue with others
I feel like an escapegoat growing up
I feel tormented and cannot stop replaying the hurt in my mind
I bully others to get back at people
I have self-pity in what has happened to me by others
I compare myself to others
N/A
Yes - I can forgive all
No - I cannot forgive any
No - some I cannot forgive
Yes been in jail
No never in jail
No but been in trouble with law but not in jail
Were you planned child: Yes
Were you planned child: No
Were you planned child: Unsure
Were you the right sex: Yes
Were you the right sex: No
Were you the right sex: unsure
Were you adopted: Yes
Were you adopted: No
Were you adopted: unsure
Was your mother in trauma during pregnancy with you: Yes
Were your mother in trauma during pregnancy with you: No
Was your mother in trauma during pregnancy with you? Unsure
Did you bonded at birth? Yes
Did you Bonded at birth? No
Did you bonded at birth? Unsure
Is you father a Christian: Yes
Is you father a Christian: No
Is your father a Christian: Unsure
Is your mother a Christian: Yes
Is your mother a Christian: No
Is your mother a Christian: Unsure
Were you raised in a Christian home: Yes
Were you raised in a Christian home? No
Were you raised in a christian home: Unsure
Was your father: Passive
Was your father: Strong and manipulative
Was your father: Neither Passive nor Manipulative
Was your mother: Passive
Was your mother: Strong and manipulative
Mother was neither manipulative or passive
Was your unbringing in an alcoholic or drug domiinated home? Yes
Was your unbringing in an alcoholic or drug dominated home? No
Was yours a happy home during childhood? Yes
Was yours a happy home during childhood? No
Were you lonely as a teenager? Yes
Were you lonely as a teenager: No
Were you lonely as a teenager: Unsure
Father was a perfectionist and I could not live up to his expectations? Yes
Was your father was a perfectionist and I could not live up to their expectations: No
Mother was a perfectionist and I couldnot live up to their expectations: Yes
Mother was a perfectionist and I could not live up to her expectations: No
Were you raised in a physically or verbally abusive home? Yes
Were you raised in a physically or verbally abusive home? No
Were you sexually abused at home? Yes
Were you sexually abused at home? No
Were you ever sexually abused outside the home? Yes
Were you ever sexually abused outside the home? No
Describe your family financial situation? Poor
Describe your family financial situation: Average
Describe your family financial situation: above average
Growing up in my house I was safe place 75% or more
Growing up I did not feel safe less than 50% of the time
Parents Went Through a Divorce And I Felt It was Your Fault
I was driven to please a parent to get love and never got it.
I am Performance Oriented to feel good about self or to get praise
Other
Born out of Wedlock: Yes
Born out of Wedlock: No
Felt like wrong sex: Yes
Felt like wrong sex: No
Were your parents married when you were conceived: Yes
Were your parents married when you were conceived: No
Foster Care: No
Foster Care: Yes
Discrimination (sex, religion, race, age, etc.): Yes
Discrimination (sex, religion, race, age, etc.) No
Shunned/excommunicated: Yes
Shunned/excommunicated: No
Bullied: Yes
Bullied: No
N/A
My Mom Rejected Me
My Dad Rejected Me
My Siblings Rejected Me
My Friends Reject Me
At Church I Don't Fit In
At Work I Don't Fit In
I Feel Insecure
I Feel Accusation by Others
I Feel that God Rejected Me
I Have Self-Pity
False Burden Bearing
Hard For Me To Make Decisions (double-minded)
I Suppress My Feelings
I Have A Broken Heart
Fear of Intimacy
Need For Love, Need for Approval, Need For Acceptance
Need for Identity
I feel depressed 50% of the time
I feel despair 50% of the time
I Feel Dejected
I take on false responsibility
Discontentment
Unthankfulness
Murmur and Complain
Depression 50% of the Time
Fabricated Personality to Fit In
Lust Fantacy Lust
I Reject Others Before They Reject Me
I Pick Fights So Others Will Reject Me
Something Must Be Wrong With Me
I Don't Feel Like I Belong Even Though I want to belong
I Have Shame and Guilt
I Have Fear of Man
I Have Fear of Rejection
I Suffer From Schizophrenia
Not nurtured or loved by parent(s) or husband(s)
My heart was broken by my family
N/A
3 and more times
1 to 2 times
None at all
Most of the time
Some times
Never
Burst of Anger: Many times
Burst of Anger: Sometimes
Burst of Anger: Rarely
Jealousy
Cruelty
Coveting with others have
Strife with others
Suppressed anger
Want to get even: Revenge
Extreme competition
Violence
Spite
Causing division
Envy of others
Hatred when others rewarded
Bigotry and racism
Desire to murder the person who hurt me
Resentful
Frustrated with others a lot
Slander other when I get hurt
Gossip
Profanity
Accusation when others don't hear me
Frenzied emotional actions
When mad I throw things
When mad I slam doors
When made I hurt my body
Hard for me to forgive others when I get hurt
N/A
Sex outside the marriage: Habit Sex
Sex outside the marriage: Some Sex
Sex outside the marriage; No Sex
Sexual Perversity
Masturbation
Molestation
Computer Pornography
Homosexuality Struggle
Sexual Frigidity
Prostitution
A fifthy mind
Self lover
Lust
Vain Imaginations
Emotional Frigidity
Sexual spirits attacking me in the night
Unfaithfulness to spouse
Spouse Unfaithful to me
Like violent sex
Bisextrous
Like Anal Sex (Sodomy)
Done Sex Magic
Done Beastiality
Peeping Tom
Pedophilia
Exhibitionism
Voyeurism
Masochism
Watch Sex Rated Movies
Seducer
Like to make others fall into sex
Jezebel Seducing Men
Raped someone
Sex oragies with 3 to 5 people
Vanerial Diseases
Very sexually active (more than 15 sexual relationships)
Lesbianism
Incest
Phone Sex
Danced at Strip Clubs
Necrophelia
N/A
Adult Babies
Water Sport - act of being aroused by urine
Cross Dressing
Sexual Role Play
Dominance/Submission
Yes
No
Anorexia
Bulemia
Self-Cutting
Self-Harming
Gluttony
Many Tatoos to deal with emotional pain
Many Piercing on Body besides ear
Other
Feelings of Murder: Yes
Feelings of Murder: No
Feelings of Murder: Unsure
Abortion in Ancestral History: Yes
Abortion in Ancestral History: No
Abortion in Ancestral History: Unsure
Have you had an abortion or helped someone get an abortion: Yes
Have you had an abortion or helped someone get an abortion: No
Self Harm: Yes
Self Harm: No
Ever tried to take your life: Yes
Ever tried to take your life: No
I wish I was dead today
Other
N/A
Food Addictions (Gluttony)
Sleep Aid
Sex Outside of Marriage
Television
Diet Pills
Workaholism
Alcoholism
Spending Money (shop-o-holism)
Caffeine
Gambling
Street Drugs
Pornography
Shopping
Smoking
RX Drugs
Compulsive Exercise
Fetishism
Internet/Video Games
Computer
Drugs: LSD
Drugs: Cocaine
Drugs: Downers
Drugs: Pain Medicine
Drugs: Speed
Drugs: Marajuana
N/A
Arrogance
Boastful/bragging
Contentiousness
Defensiveness
Obstinacy
Overbearing
Idleness
Controlling
I have to be perfect
I see myself perfect
Everyone else is always wrong
Other
N/A
Yes excessive mourning
Yes self-pity
Yes bitterness
Yes Sorrow
N/A
I am all alone
I don't matter
God has forsaken me
I have been overlooked
I am so stupid, ignorant and idiot
I should have not been born
I am bad, dirty, shameful, sick and nasty
No one cares
Everything is out of control 50% of the time
I am not loved, needed, cared for or important
I am worthless and have no value
I was a mistake
I was never liked by them
I am a burden
I could never jump high enough to please him/her
It is never going to get any better
I have no reason to live
I just want to die
My life is ruined
I will never feel clean again
I am unimportant
I should have never been born
God could never love or accept me
I don't feel his love
I know God does not love me
I am a failure to God
N/A
Yes
No
I day dream a lot
I have memory gaps - cannot remember grade school years
Diagnosed with MPD/DID
I live in fantasies
ADD/ADHD
I have amnesia
Been diagnosed with Schizopohrenia
Been diagnosed with Paranoia
I suffer with madness
I suffer with Hallucinations and see people or dead people
I suffer from mental illness
I've been diagnosed with Bipolar
Other mental diagnosis
N/A
Oppression
Heaviness
Doubt and Unbelief
Doubt my salvation
The voices tell me I am not forgiven
Voices tell me I am going to hell
N/A
Big issue
Some issue
None at all
Big problem
Small problem
None at all
Yes, mind cannot stop when resting
No, I can rest
Not for sure
Born with cord around your neck
Born prematurely and separated
Car Wreck
Sudden Surgeries
Verbal Abuse
Physical Abuse
Rape
Almost Drowned
Almost Died
Bullied by someone
Witness Mother Being Abused by Dad
Diagnosed with a life-threatening illness
Not feeling safe on ongoing basis in the home
Kidnapping
Forced abortion
Major Slander by Someone
Victim of racial prejudice or cultural prejudice
Sudden Financial Loss Where Your LIfe Changed
Graphic violent movies and horror movies that disturbed me
Robbery
Physical assault such as mugging or carjacking
Been Shot At by Someone Trying to Hurt You
Major catastrophic events such as a plane crash or terrorist act
Exposure to acts of war/terrorism/political violence
Extreme Embarrassment
abusive, manipulative, domineering, controlling, micro managing Boss That Put Fear In You in a daily basis,
Controlled by a pastor
Hurricane, Tornadoes, Earthquakes
Fire
Locked in Closet
Neglected by Parents
Betrayal by someone I trusted and broke my trust
You've Been Tortured
Forced to have an abortion over your will
Satanic Ritual Abuse
Born in a cult
Abandoned and given away to the system
N/A
Opression and Heaviness
Nightmares
I Experience unusual fears
I cannot control my anger
Feelings of Guilt and Shame
Hopelessness
Fatigue
Phobias
Over react to noise
Memory Gaps
Sleep Disorders
Panic Attacks
Anxiety Attacks
Obsessive Compulsion
Feeling ruined
Restless Leg Syndrome
Fear of the opposite sex
Confused what love is
Overwhelming feelings
I cannot focus
Fear of Germs
Fear of Animals
Fear of Bugs
Fear of Heights and Bridges
I live by a list
I fear that I could not live up to other people's expectations
I grew up in a conditionally loved home
I am a perfectionist
I am a perfectionist, performance driven person for approval and love
I will perform in all areas to feel good about myself
I'm an extrovert
I'm an introvert
I smoke out of nervousness
Other
N/A
Fear of tomorrow or future
Worry about tomorrow like my kids, job, etc.
Dread - I project evil into the future
Fear of change
Distress
Fear of loss
Fear of Death
Fear of dying process
Fear of losing my children
Fear of loss of relationships
Fear of disease
Fear of cancer
Fear of Pain
Fear of Suffering
Fear of Diability
Fear of disfiguration
Fear of doctors/hospitals
Fear of needles, blood
Fear of God in a negative way
Fear of God punishing me
Fear of Evil Spirits
Fear of bad news
Fear of betrayal
Fear of man
Fear of public speaking
self-consciousness
Shyness
Fear of criticism
Fear of inadequacy
Fear of reproof
Fear of other people's facial expression
Fear of another person's bitterness
Fear of disapproval
Fear of verbal rejection
Fear of being reproached or being shamed
Fear of humiliation
Fear of what people think of me
Fear of races/cultures
Fear of rejection
Fear of abandonment
Fear of being alone
Fear of loneliness
Fear I will never get married
Fear of not having enough
Fear of poverty and lack
Fear of failure
Fear of insanity
Fear of the dark
Fear of the dark
Fear of antigens
Fear of certain foods, drink, clothing, housing, environment and chemicals
Fear of allergic reactions
Fear of success
Perfection, Performance and Driveness
Fear of being controlled by others
Fear of a family member
Fear of spouse
Fear of my child(ren)
Fear of authority
Fear of the water
Fear of dependency
Fear of being robbed
Fear of terrorism
Fear of tight spaces
Fear of crowds
Fear of menopause
Walking on eggs growing up not knowing when you are going to get hit or yelled at
Other
N/A
Being a victim of terror
People I love dying
I have fear talking to strangers
I have a desire to be a hermit or recluse
I fear heart attacks
I fear death
I have germphobia
I have Acraphobia
A constant desire to be alone
I fear that I am not good enough
I suffer with torment - horror
I have anxiety, stress and worry
I have panic and anxiety attacks
I suffer from migraines
I have fear of authority
I have a critical spirit
I have fear of Cyber-terrorism
I fear change
I have an unhealthy fear of God
I am introverted
I fear saying no
I fear Pandemic
I fear heights
I fear leaving my home
I fear flying
I fear heights and bridges
I fear tight places
I fear others controlling me
I am a perfectionist
I have to perform to feel good
I have phobias
I have had traumatic events in my life
Growing up I had to walk on eggs around both or one of my parents
I never could meet up to my parents expectations
I grew up in a conditionally loved home through performance
I have fear of the opposite sex
I was driven to perform for my parents to get their approval and love
I was driven to perform so that I would not get hurt/abused physically or emotionally by them
Because of my fears, I try to fix others
N/A
I must be very guarded about what I say since anything I say may be used against me - family I grew up with
I must be guarded about what I say since anything I say may be used against me - spouse
I have to guard and hide my emotions and feelings when growing up
I have to be guarded and hide my emotions and feelings with my spouse
I cannot give anyone the satisfaction of knowing that they have wounded or hurt me. I'll not be vulnerablel, humiliated, or shamed
The best way to survive is to avoid, overpower other people
I will always need to be strong in order to protect and defend myself
It's not safe to submit myself to anyone
I've been hurt to many times and cannot let anyone get close to me
Moved a lot growing up and don't get close to people today
Other
N/A
Yes
No
Yes
No
Yes
No
Per Week
Per Month
Year
None at all
Yes
No
Sometimes
Yes
No
Two Hours
Three Hours
Four Hours
Monday 7:30 p.m. central standard time
Wednesday 7:30 p.m. central standard time
Thursday 7:30 p.m. central standard time
Saturday 9:00 a.m. central standard time
Saturday 11:30 a.m. central standard time
Sunday 3:00 p.m. central standard time
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