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 [PERSONAL HISTORY] 1. Your Name: 2. Address: 3. Telephone: 4. Email Address: 5. Occupation: 6. Date of birth: mm/dd/yyyy 7. Sex: 8. Education: 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? [PARENTS RELATIONSHIP] 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: [FAMILY HISTORY] 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 Introvert Ambitious Self-confident Persistent Impatient Moody Calm Easy-going Likeable Quiet Sensitive Lonely Nervous Impulsive Excitable Serious Shy Leader Submissive Self-conscious Perfectionist People pleaser [EDUCATIONAL INFORMATION] 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] PHYSICAL: 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.? SUBSTANCE ABUSE: 35. Age when using alcohol: 36. Age at first use of drugs: 37. Drug or Drugs used: How used? How long? PORNOGRAPHY: GANG INVOLVEMENT: 38. Age when involved: EMOTIONAL: 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. Inferiority Fantasy: Obsessions Compulsiveness Worry Doubt Suspicion Suicidal or criminal thoughts Lust Blasphemous 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? Explain: 43. Check and explain any of the following with which you are having or have had a problem: Insecurity Fear Guilt Anger Anxiety Unworthiness Low-self esteem Loneliness Depression Hatred Bitterness Rebellion Envy Jealousy Pride Unforgiveness Revenge Overly sensitive Easily offended Self centeredness Self pity Comparing Regret Disappointment Sadness Injustice Rejection Resentment 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 Explain: 47. Have you ever been in trouble with the law? Yes/No Explain: [RELIGIOUS BACKGROUND] 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: Astro projection: Christian Science: Zen Buddhism: Ouija Board: Hare Krishna: Table lifting: Scientology: Speaking in trance: Baha’iism: Rosiorucianism: Automatic writing: Telepathy: Science of mind: Jehovah’s witness: Clairsentience: Fortune Telling (Tarot cards, palm reading, etc.) : Visionary dreams: Amateur Hypnosis: Materialism: Transcendental meditation: Palm reading: Swedenborgianism: Astrology: Rod & Pendulum (dowsing): Yoga: Unitarianism: Silva Mind Control: New age: Freemasonry: Healing magnetism: Magic charming: Magic (black or white): Islamism: Blood pacts: Hinduism: Clairvoyance: Children of God: Worldwide Church of God (Armstrong): Unitarianism: Mormonism: Speaking in trance: Science of the Creative Intelligence: Echkantar: Roy Masters: EST: Theosophical Society: Black Muslim: Tarot cards: 66. Have you ever experienced hearing voices? Describe any other experiences you may have had that would be considered out of the ordinary. [SEXUAL HISTORY] 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: [MARITAL INFORMATION] STATUS 72. Married/single/separated/divorced? 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? [ADDITIONAL INFORMATION] 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. [RELEASE AGREEMENT] 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. YOUR SIGNATURE: (type your name here) DATE: