Você está na página 1de 10

Spiritual Counseling Questionnaire The purpose of this questionnaire is to obtain information that will be helpful to your counselor in determining

the prospect of demonization and the inroads or open doors through which the demonic powers have gained entrance into the counselees lifefor the objective of deliverance, spiritual warfare, and counseling. The information you provide as well as all matters discussed during counseling are completely confidential, and this sheet is only available to your counselor and will not be seen by anyone else. Responses to all questions are entirely optional. However, the more information you provide, the more and more easily we will be able to help you. Complete honesty and forthrightness with yourself, God, and your counselor is essential to effective counseling and deliverance. CONTACT / PERSONAL INFO Date of initial visit ______ /_______ /_________ First Name:_________________________ Last Name:__________________________ Age:_____ Phone (______) ________ ___________ Email Address:_________________________________ Referred By:_________________________________

Church Affiliation:______________________________ Year Baptized: __________________ Confirmed:_____________ PERSONAL ISSUES (List all that you are struggling with now.) 1) 4) 2) 5) 3) 6) EMOTIONAL PROBLEMS (Check all that apply that are of a persistent nature) __ Depression __ Suicidal Ideation/acts __ DID __ Schizophrenia/Schizothymia __ Anger toward whom? __ Rage toward whom? __ Hate toward whom? __ Unforgiveness toward whom? CONFLICTS WITH PEOPLE Do you have any persistent conflicts in your family relationships? __ Yes __ No If yes, with whom?_____________________________ Do you have any persistent conflicts with another person or persons besides your family? __ Yes __ No If yes, explain:

EXTREME OR ABNORMAL CONDITIONS (Check all that apply) __ Fears/Phobias __ Resentment Discontentment with: __ Self-pity __ Bitterness __ Self __ Envy __ Racism __ Spouse __ Pride __ Anti-Semitism __ Family __ Jealousy __ Unbelief __ Current Circumstances __ Unpredictability __ Doubt __ __ Self-punishment __ Mental/Emotional (describe) __ Physical (describe) __ Others: TRAUMATIC EXPERIENCES (Check all that apply) __ Childhood __ Adolescence __ Adulthood __ Abortion __ Murder __ Rape __ Incest __ Molestation

__ Sexual abuse __ Emotional abuse __ Controlled by another __ Sudden death of a loved one __ Physical attack __ Other _________________________________________ __ Divorce of parents Divorce run in your family? __ Yes __ No Explain checked answers (what sort of trauma, who was involved): ______________________________________________________

DESTRUCTIVE HABITS (Check all that apply) __ Lying __ Blasphemy __ Abuse __ Gossip __ Criticism __ Temper/Anger Fits __ Drugs __ Drinking __ Gluttony __ Anorexia __ Bulimia __ Tobacco use __ Sniffing __ Stealing __ Vandalism __ Cutting self __ Pulling hair out __ Others: IMMORAL ACTIVITIES (Check all that you have participated in) __ Homosexuality __ Lesbianism __ Bi-sexuality __ Adultery __ Fornication (unwed sex) __ Masturbation __ Incest __ Sodomy __ Rape __ Pornography/Fantasy Lust __ Bestiality __ Lust __ Voyeurism __ Exhibitionism __ Orgies/Mate Swapping __ Others (list:)

Describe: __ I have had desires for these sorts of things listed above, but have not acted upon them. List which one(s): __ I possess pictures/videos/books of the above acts being performed. List which one(s):

Negative Connections A Negative Connection is any improper, unbiblical, or ungodly relationship involving unnatural, excessive devotion, dedication, or affection. These can occur between friends, relatives, spiritual cohorts, intimates, student-teacher, protg-mentors, and other types of relationships. Generally, some form and degree of seduction and predomination by one party over the other is involved in the relationship. Improper, unbiblical, and demonically inspired covenants, pledges, and oaths are sometimes involved. __ Emotional With whom?________________________ __ Sexual With whom?___________________________ __ Psychological With whom?__________________________ __ Spiritual With whom?______________________________ __ Other With whom?__________________________ TATTOOS, BODY PIERCINGS, AND OTHER BODILY ALTERINGS Please list and describe any tattoos, body piercings, or other defilements of your body:

OCCULT ACTIVITY PAST OR PRESENT __ Shaman/Witchdoctor __ Witch/Warlock __ Spiritualist healer __ Voodoo Practitioner __ Psychic healer __ Metaphysical healer __ Christian Scientist __ Acupuncture Ever sought or been subject to any form of occult prognostication, such as: __ Pendulum __ Divining (e.g. water witching rods, wedding ring, needle and thread, et al.)? Ever used or worn: __ amulet __ talisman __ rabbits foot __ magic or good luck charms? Ever been involved in Halloween trick or treating, haunted houses, or other fright activities? __ Yes __ No Ever practiced or been involved with: __ Spells/hexes __ Meditation __ Telepathy __ E.S.P. __ Mental suggestion Ever studied, read about, played, performed, or participated in: __ Wicca __ Witchcraft __ White/Black magic __ Spirit Guide __ Satan or Angel worship __ Sance __ Vampirism __ Blood drinking __ Blood spilling __ Medium channeling __ Yoga __ Hypnosis __ Horoscopes/Astrology __ Ouija Board __ Tea leaf reading __ TM __ Palm reading __ Tarot card reading __ Levitation __ Automatic (spirit) writing __ Occult video games __ occult or new age books

Ever sought or used a: __ psychic __ medium __ spiritist __ witch/witchdoctor __ crystal ball gazer Ever had a/an: __ imaginary playmate __ spirit-visitor __ visitation of deceased ancestors DEMONIC, RELIGIOUS, OCCULT PARAPHERNALIA (Check all in your home or in/at/on any property you own) __ Tarot Cards __ Crystal __ Energy Balls __ amulets __ Good luck charms/jewelry __ Occult jewelry __ Heavy Metal or Rap music __ occult games __ Medallions or statues __ Demonic, occult, or pagan art objects, relics, artifacts, or images (e.g., Buddhas, Sun gods, Egyptian gods) __ Mormon, Jehovah Witness, Catholic, or Christian Science paraphernalia __ Free Masonry paraphernalia __ Relics, artifacts, or other paraphernalia that may have been used in pagan temples, religious rites, or in the practice of sorcery, magic, divination, or spiritualism. __ Native American religious paraphernalia, art objects, relics, artifacts, or images (e.g., dream catchers, peace pipe) __ Demonic books, comics, or videos on: __ Vampires/werewolves __ the weird __ Horror __ Occult, spiritualism, or new age books or other publications on: __ Astrology __ Horoscopes __ Dream Interpretation __ Fortune telling __ Metaphysics __ Religious cults __ Eastern Religious __ Self-realization __ E.S.P. __ Clairvoyance __ Mind control __ Psychic phenomena

__ Meditation __ New Age Topics __ Black/White magic __ Altered Consciousness __ UFOs __ Paranormal __ Numerology __ Halloween, St. Patricks Day, Easter Bunny paraphernalia __ Other: CULTS AND FALSE RELIGIONS (Check any with which you have had direct or indirect involvement) __ Christian Science __ Scientology __ Unitarianism __ Latter Rain __ Children of God __ Armstrongism __ The Way __ Hare Krishna __ WICCA __ The Forum __ Zen Buddhism __ Buddhism __ Hinduism __ Shintoism __ Witchcraft __ Satanism __ Mother Earth __ TM __ Islam __ Unification Church __ Spiritual Frontiers Fellowship __ Religious Research of America __ Animism __Other:

Have you, any of your relatives, or anyone with whom youve had a romantic relationship ever been involved in: __ Masonic Lodge __ Shriners __ Illuminati __ Eastern Star __ Other secret society: DRUG AND ALCOHOL HABITUATION AND ABUSE (Check any of the following you have used) __ Marijuana __ Hashish __ Peyote __ Crack __ Cocaine __ Heroin __ LSD __ Methedrine __ Nembutal __ THC __ STP __ Speed __ Amphetamines __ Sleeping pills __ Pain killers __ Antidepressants __ Antipsychotics __ Ecstasy __ Other drugs, narcotics: __ Habitual or frequent excessive drinking, recreational drinking, drunkenness, alcoholism

Have you ever been involved in the sale or distribution of illegal drugs? __ Yes __No CONDEMNATION GUILT __ Regarding past sins in general __ Fear of committing sins __ Fear of not being forgiven __ Unforgiveness of self __ Unpardonable Sin __ Abortion __ Divorce / remarriage __ Other Explain checked answers here:

GENERATIONAL INIQUITY/CURSES (INIQUITY OF THE FOREFATHERS) Some demons gain entrance and have a legal right to operate through generational iniquity (perversion), i.e., the iniquity of the fathers. List below known iniquities or habitual sins of your ancestors you have also experienced? Mothers sin issues: Fathers sin issues: Grandpa (Mothers side): Grandma (Mothers side): Grandpa (Fathers side): Grandma (Fathers side): Great-grandparents: Siblings: Uncles, aunts, relatives:

OTHER NOTES AND COMMENTS

Você também pode gostar