Binding Up the Brokenhearted Enrollment

Step #6 – Client Information Questionnaire

It is standard practice to gather information at the beginning of any counseling relationship, as it provides valuable insight to the counselor. Filling out this form is completely voluntary. We ask for this information so that we can minister to you more effectively. If there are questions that you prefer not to answer, leave them blank. Any information provided to us will be kept confidential.

General Information

1. Do you have any fears about participating in this Bible study? If so, please explain.
2. What would you like to accomplish by enrolling in this Bible study?
3. Briefly describe how you feel about your abortion(s) at this time.
4. How did you find Healing Hearts Ministries? (a search engine, brochure, radio program, referral… etc)

Family History

1. Your age range: Prefer not to answer10-2021-3031-4041-5051-6060+
2. Are you married?
3. Do you have any children? If so, how many and what are their ages?
4. How would you describe your relationship with your spouse?
5. Have you ever had an adulterous affair? If so, when?
6. Has your husband ever had an adulterous affair? If so, when?
7. Have any of your parents, grandparents or great-grandparents, to your knowledge, ever been involved in any occult, cult, or non-Christian religious practices? If so, what was their involvement?
8. Briefly explain how your parents felt about spiritual things.
9. Are your parents currently married, divorced, or separated?
10. Was there a sense of security/harmony in your home during the first twelve years of your life?
11. How did your father treat your mother?
12. Was there ever an adulterous affair with either your parents or grandparents?
13. Were there any incestuous relationships within your family? If so, who was the abuser and who did they abuse?
14. Have either your mother or grandmother had abortions?
15. Are you or any of your brothers or sisters adopted?

Health History

1. Are there any addictive problems in your family history (alcohol, drugs, gambling, shopping, sexual activity, pornography etc.)? If yes, please be specific.
2. Any history of mental illness? If so, whom?
3. What was the diagnosis and how are they related to you?
4. Are there any chronic medical issues or diseases that have been diagnosed for either you or a family member? (Some chronic illnesses or diseases such as emphysema, HIV, HepC and diabetes can cause periods of emotional anxiety, fear and depression as well as physical pain.)
5. When was the last time you had a complete physical examination?

Personal

1. Do you have any addictions or cravings that you find difficult to control (food, sweets, drugs, alcohol, etc.)? Please explain.
2. Are you currently under a doctor’s care for emotional problems?
3. Are you currently taking any medications? If so what kind of medication, and what is it for?
4. Are you currently receiving counseling?
5. Who are you receiving counseling from? Check all that apply.
   • Pastor
   • Church Program
   • Biblical Counselor
   • Psychologist
   • Psychiatrist
6. Who referred you to this counselor?
7. How long have you been seeing this person and for what reason?
8. Are you currently involved in any counseling or 12 step groups? If so, what groups, and how long have you been involved?
9. Do you have any problems sleeping? Are you having any recurring nightmares or disturbances? If so, please explain.
10. Does your present schedule allow for regular periods of rest and relaxation?
11. Have you ever been physically beaten? If so, by whom?
12. Have you ever been sexually molested? If so, by whom?
13. Do you find yourself struggling with any of the following:
    • Daydreaming
    • Inadequacy
    • Fantasy
    • Blasphemous Thoughts
    • Headaches
    • Lustful Thoughts
    • Worry
    • Obsessive Thoughts
    • Compulsive Thoughts
    • Inferiority
    • Doubts
    • Insecurity
    • Dizziness
    • Angry thoughts
14. Have you ever thought that maybe you were “going crazy” and do you presently fear that possibility? (Please explain)

Spiritual History

1. If you were to die tonight, do you know where you would spend eternity? Please explain.
   1 John 5:11-12 says, “God has given us eternal life, and this life is in His Son (Jesus). He who has the Son has the life; he who does not have the Son of God does not have the life.”
2. Do you have a personal relationship with Jesus?
3. When did Jesus come into your life?
4. Do you read the Bible? If so, how often?
5. Do you pray? If so, why?
6. Do you find it hard to talk to God in prayer?
7. How important is it that you are honest before God, and do you feel that you are?
8. If you are a Christian, are you plagued with doubts concerning your salvation?
9. Are you presently enjoying fellowship with other Christian believers? If so, where and when?
10. Do you attend a church? If yes, what church do you attend?
11. Do you currently feel unworthy before God? If so, please explain.