YEAR OF: Birth ____ Received Jesus ____ HS Graduation ____ Wedding ____
Are you on medication, a) now or b) previously (please circle one)
SPIRITUAL PROBLEMS WITH
___ Bible Reading
___ Church Attendance
___ Prayer
___ Spiritual Apathy
___ Witnessing
RELIGIOUS BACKGROUND
___ Catholicism
___ Christian Science / Scientology / Unitarianism
___ Far Eastern Religions / Hindu
___ Islam / Muslim
___ Jehovah’s Witnesses
___ Legalistic Abuse (Rules/Do’s & Don’ts)
___ Mormonism
___ Native American Religion / Rituals
___ New Age
___ Pentecostal / Assembly of God
___ Religious Lodges (Masonic / Free Masonry / Shriners)
___ Rituals (Religious / Occult / Cult / Other)
___ Santeria
___ Other
___ Possess “cult” paraphernalia currently
I HAVE EXPERIENCED THE FOLLOWING
___ Charismatic Doctrinal Background
___ I have been slain in the spirit
___ I speak in tongues
___ I am willing to test the Tongue (1 John 4:1)
ADDICTIONS/SUBSTANCE ABUSE
___ Alcohol
___ Drugs / Prescriptions
___ Fitness / Over Exercise
___ Food / Overeating
___ Gambling
___ Rock Music / Rap / Heavy Metal
___ Tobacco
___ TV / Video Games / Computers
___ Ungodly Music CD’s / tapes / Videos / Pictures / Games in possession
___ Workaholic
___ Other
BEHAVIORAL CHARACTERISTICS
___ Anger / Hatred / Rage
___ Anxiety / Worry
___ Arrogance / Self Righteousness
___ Bitterness / Resentment toward others
___ Bitterness toward God
___ Controlling / Manipulative / Need for power
___ Critical Spirit / Gossip / Slander
___ Cursing / Swearing
___ Distrust / Lack of trust (of God / Others)
___ Fighting / Quarreling
___ Grumbling / Complaining / Discontentment
___ Hypocrisy
___ Independent
___ Indecisive
___ Impatience / Irritability
___ Isolation / Loneliness
___ Jealousy / Envy / Coveting
___ Lack of Submission to Authority Figures
___ Laziness
___ Lying / Deceit
___ Moodiness / Severe Mood Swings
___ Nightmares (If so, demonic? / or being “chased” in dreams?)
___ Panic Attacks
___ Prejudiced / Racist
___ Pride
___ Rebellious (toward God or others or both?)
___ Rejection / Abandonment
___ Self- Mutilation
___ Stealing
___ Suicide Thoughts / Attempts
___ Tendency to Blame others / Not take responsibility
___ Timid / Shy
___ Unforgiveness
___ Violent
MISCELLANEOUS
___ Adopted
___ Committed a crime / spent time in jail or prison
___ Excessive bed wetting when young
___ Financial Chaos (extreme debt)
___ Flashbacks of any kind
___ Have you lived in other Countries
___ Overwhelming Grief (i.e.: death of a loved one)
___ Tattoos
___ Trauma from an accident
___ Victim of Racism / Prejudice
___ Victim of any other kind of injustices
___ War Veteran
___ Other
OCCULT INVOLVEMENT
___ Astral Projection / Out of body Experience(s)
___ Astrology / Horoscopes
___ Auras
___ Automatic Writing
___ Blood Sacrifices / Pacts / Dedications
___ Channeling / Speaking with spirits
___ Charms / Fetishes / Crystals
___ Cult related paraphernalia in possession? (Books / Jewelry / etc.)
___ Curses (have you cursed someone or been cursed)
___ Do you have in your home symbols of idols / spirit worship
___ Do you possess pagan objects / Relics
___ Fortune Told / Palm Reading / Rune Stones
___ Have objects moved in your house without a source
___ Horror Movies (excessive interest)
___ Hypnotism
___ Levitation/ Table Tipping
___ Meditation (including through Martial Arts)
___ Numerology
___ Occult Books / Comics / Literature / Video Games
___ Occult related paraphernalia in possession? (Books / Jewelry / etc.)
___ Ouija Board / Crystal Ball
___ Participation in any Pagan / Occult Ceremonies
___ Psychic healing
___ Role Playing Games / D&D
___ Satan Worship / Witchcraft / Wicca
___ Séances
___ Spell Casting / Hexes
___ Spirit Guides / Imaginary “Friends”
___ Tarot Cards
___ Telepathy / Clairvoyance
___ Time Curses
___ Voodoo
___ White/ Black Magic
___ Yoga / Transcendental Mediation / Mind Control
___ Possess Occult Paraphernalia currently
FEARS Primary Historical Fears (recent or past)
1.
2.
3.
4.
5.
KNOWN GENERATIONAL SIN
Father / Father’s Family Line
Mother / Mother’s Family Line
MENTAL/PSYCHOLOGICAL ISSUES
___ Acute Nervousness
___ Bipolar / Manic Depressive
___ Confusion / Concentration
___ Depression / Discouragement
___ Emotional Extremes (Happiness / Sadness)
___ Emotional Lack (Happiness / Sadness)
___ Extreme Forgetfulness
___ Hallucinations
___ Hearing voices in the mind
___ Hopelessness
___ Inferiority / Insecurity / Low Self Esteem
___ Memory Loss / Few memories from youth (good and/or bad)
___ Neglected (childhood / youth / adult)
___ Obsessive / Compulsive Behaviors
___ Perfectionist
___ Persecution Complex / Paranoia
___ Psychiatric / Psychological Counseling (for any reason)
___ Schizophrenia
___ Shame / Guilt / Condemnation
___ Trouble Giving or Receiving Love
___ Unbelief of God / Doubting God
___ Visions (of any kind)
___ Other
SEXUAL
___ Abortion
___ Adultery
___ Bestiality
___ Children born out of wedlock (you or YOUR child(ren)
___ Difficulty getting pregnant
___ Exhibitionism
___ Flirtatious / Seductive
___ History of Unfaithfulness (with or without intercourse)
___ Homosexuality
___ Impotence / Frigidity (lack of sexual desire)
___ Incest (including touching while playing “Doctor”)
___ Lesbianism
___ Lust / Fantasy
___ Masturbation
___ Molestation (done to you or you have done)
___ Pedophilia (child sex)
___ Pornography (including Internet)
___ Pre marital Intercourse / Immorality / Promiscuity (w/ others)
___ Pre marital Intercourse / Immorality (w/ SPOUSE)
___ Prostitution
___ Rape
___ Soap Operas / Romantic Novel (watch / read regularly)
___ Strip Clubs
___ Unwanted / Unplanned Pregnancies (YOU or you had)
Yes / No Are you currently in a relationship?
If yes, for how long ____
Yes / No Is the relationship currently free of all immorality?
If not, for how long ____
PHYSICAL PROBLEMS
___ AIDS
___ Cancer
___ Chronic Back Trouble
___ Chronic Fatigue / Fybromyalgia
___ Dizziness / Blackouts
___ Eating Disorders (Anorexia / Bulimia)
___ Frequent Illnesses
___ Headaches / Migraines
___ Hyperactivity / ADD / ADHD
___ Hypoglycemia / Diabetes
___ Joint Pain / Arthritis
___ Menstrual Problems / PMS
___ Miscarriages
___ Seizures / Epilepsy
___ Sinus / Throat / Ear Problems
___ Stress / Tension
___ Sudden Sleepiness / Insomnia
___ Teeth Grinding / TMJ
___ Tiredness / Exhaustion
___ Trauma at birth (YOU or you had)
___ Vision / Eye Problems
___ Other
ABUSE
___ Physical
___ Psychological / Emotional / Mental
___ Satanic Ritual Abuse (SRA)
___ Sexual
___ Spiritual / Religious
___ Verbal (“word curses”)
___ Other
FINAL SCREENING
RELATIONAL DIFFICULTIES
___ Father / Mother
___ Step Father / Mother
___ Guardians
___ Other Relatives (Grandparents / Aunts / Uncles / Cousins)
___ In-laws
___ Are you a child of a divorce situation
___ Have you been separated / divorced yourself
___ Relational Victimization
___ Other Relational Victimization
Father’s Name __________
Step Father’s Name __________
Mother’s Name _________
Step Mother’s Name _________
Guardian’s Name __________
Your Sibling’s Names / Ages (and any relational difficulties with them)
1.
Scotty Kessler Resource Library 