The Father's House - OH

First Name

Last Name

Email

Phone Number

Date of Birth

Gender

Marital Status

Education (highest grade)

# of Siblings /# of Brothers/ # of Sisters

Were you adopted?

Yes

No

Were you raised by someone other than your parents?

Yes

No

If yes, explain:

Did your parents want you?

Is it likely they were fighting while you were in the womb?

Yes

No

Was there a sense of security and harmony in your home during the first twelve years of life?

How was authority exercised in the home? Which parent was in charge and how did he or she operate?

How was affection shown between your parents and toward you?

Marriage Information

Name of Spouse (if married)

Spouse's Age

Spouse's Occupation

Date of Marriage

Ages at Marriage (Husband/Wife)

Have you ever been separated?

Yes

No

If yes, when and how long?

Have either of you ever filed for divorced or an annulment?

Yes

No

If yes, when and who initiated the filing?

Is your spouse willing to come for counseling?

Yes

No

Uncertain

Give brief information about any previous marriages:

Information about children: (Name/Age/Sex/Alive/Married)

Have you ever had a miscarriage?

Yes

No

Have you ever had an abortion?

Yes

No

Parents' Relationship

Is your father living?

Yes

No

Is your mother living?

Yes

No

Are your parents currently married to each other?

Yes

No

Are you aware of any adultery and/or incest in your family or your grandparents families? If yes, explain.

To your knowledge, have your parents, grandparents or great-grandparents ever been involved in any occult or non-Christian religious practices?

Briefly explain your parent's Christian experience (i.e. Did they profess to be Christians?) If yes, did they live out their Christianity?

Family Health History

Any addictions in your family? (e.g. alcohol, drugs, gambling, eating disorders, etc.)

Any history of mental or emotional illness?

Any history of any of the following? Tuberculosis. Heart Disease. Diabetes. Cancer. Ulcers. Glandular Problems. Epilepsy. Other significant health issues:

Describe your family’s attitude towards diet, exercise and rest:

Moral Climate

Rate the atmosphere in each of the following areas during the first 18 years of your life:

Clothing

Sex

Dating

Movies

Music

Drinking Alcohol

Smoking/Tobacco Use

Reading Material

Church Attendance

Personality Information

Have you ever had any psychotherapy, counseling, or prayer ministry?

Yes

No

If yes, which and when?

What was the outcome?

Health Information

Physical Health

List all important present or past illness, injuries or handicaps:

Date of last medical examination?

Report?

Are you presently taking any medication?

Yes

No

If yes, what medications?

Describe your eating habits (i.e. Are you a junk food or health addict? Do you eat regularly, or sporadically? Is your diet balanced?):

Do you have addictions or cravings that you find difficult to control? (Food in general, sweets, drugs, alcohol, sex)

Yes

No

If yes, what?

Mental/Emotional Health

Have you ever had a serious emotional breakdown/episode?

Yes

No

Have you ever had a serious emotional breakdown/episode? If yes, explain:

Where would you put yourself on the optimism scale? Events (i.e. Things that happen tend to be good/bad):

Pessimism - 1

2

3

4

Optimism - 5

Do you have a fear (or haveyou feared) that you might "crack up"?

Yes

No

Do you have a fear (or have you feared) that you might "crack up"? If yes, explain:

Have you been arrested?

Yes

No

Have you been arrested? If yes, explain:

How much time do you spend per week watching tv, playing video games, and on social media?

How much time do you spend per week reading? What do you read?

How much do you listen to music? What kinds?

Are you emotionally honest with God?

Yes

No

Explain previous answer:

Which of the following best describes how you handle positive and negative emotions?

I readily express all emotions

I express some of my emotions but not allice Two

I acknowledge their presence but am reserved

I tend to suppress my emotions

I find it safest not to express how I feel

I tend to disregard how I feel since I can’t trust my feelings

I consciously or subconsciously deny them since it is too painful to deal with some of them

Explain previous selections:

Religious Background

What church do you presently attend?

Who is the pastor?

Church you attended in childhood?

Baptized?

Yes

No

Religious background of spouse? (if married)

Do you know for certain you will go to heaven when you die?

Yes

No

What is your basis for answering the preceding question as you did?

Are you plagued with doubts concerning your salvation?

How much do you read the Bible?

Never

Often

Occasionally

How much time do you spend praying? Do you find praying difficult? How do you pray?

Do you have a regular time with God?

Yes

No

Do you have regular family devotions?

Yes

No

When attending Christian meetings, are you plagued with foul thoughts, jealousies, or other mental harassment? If so, explain:

Explain any recent changes in your religious life:

Have you ever taken a class or read books on parapsychology or metaphysics or had other occult involvements? If so, explain:

Have you ever heard voices in your mind? If so, explain:

Explain previous 3 sections:

Closing Questions

How would you describe your problems?

What have you done about these problems?

What are your expections in coming to us for ministry?

Is there any other information that you think we should know?

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Rapha Room Questionnaire