confidential personal inventory Confidential Personal InventoryPlease Read Carefully before proceedingATTENTION: The more you answer the questions below. The better I can assist you. Please complete and return this form. It will be used solely for the purpose of helping you take hold of your freedom in Yeshua (Jesus Christ). If you are taking this appointment self-direct, this form will be used if you wish to set a zoom appointment with Bianca. This form is confidential and you will receive a copy after the appointment. We also can destroy it and keep no record of it. The only form kept of your appointment is the basic Statement Of Understanding that you will be asked to complete just before you begin.A. Personal InformationName:Telephone: (daytime)Age:Telephone: (evening)AddressCityStateZip CodeEmailOccupation:Present:Past:Marital Status: Single Married DivorcedNo. of years Children: names (optional) and ages:B. Family HistoryWere you adopted? Yes NoWere your parents believers (i.e. Christians, “born again”)? Yes NoIf so, did they profess and live their faith? Yes NoWere your parents divorced after you were born? Yes NoWho was the authority figure in your home? Father Mother OtherExplain (Other):How did your father treat your mother?To your knowledge, was there ever an adulterous affair in your parents’ or grandparents’ relationships?Any incestuous relationships? Yes NoHave your parents, grandparents or great-grandparents ever been involved in any occult, cultic or non-Christian religious practices? Yes NoExplain:Identify the sex and age of your sibling(s) and place yourself in birth order: (Child, Sex, Age)Describe the emotional atmosphere in your home while you were growing up. Include a brief description of your relationship with your parents and sibling(s):Identify whether your parents were strict or permissive in regard to thefollowing:Clothing Overly Permissive Permissive Average Strict Overly StrictSex Overly Permissive Permissive Average Strict Overly StrictDating Overly Permissive Permissive Average Strict Overly StrictMovies Overly Permissive Permissive Average Strict Overly StrictMusic Overly Permissive Permissive Average Strict Overly StrictLiterature Overly Permissive Permissive Average Strict Overly StrictFree Will Overly Permissive Permissive Average Strict Overly StrictDrinking Overly Permissive Permissive Average Strict Overly StrictSmoking Overly Permissive Permissive Average Strict Overly StrictChurch Attendance Overly Permissive Permissive Average Strict Overly StrictC. Family HealthIs there a history of ongoing physical illness in your family? Yes NoIf Yes, please give specific disease(s)?Is there a history of mental illness in your family? Yes NoIf Yes, please explain brieflyIs there a history of addictive problems in your family? Yes NoIf Yes, to what?D. Physical HealthDescribe your general health:Are you currently under any kind of medication for either physical or psychological reasons? Yes NoExplain: Medication PurposeDo you have any problems sleeping? Yes NoDescribe your sleeping patterns (i.e. Do you have restful sleep?). Are you having any recurring nightmares or disturbances?E. Thought Life & Emotional HealthPlease tick any of the following emotions you have had or are presently having difficulty controlling (add others if necessary); frustration anger anxiety hopelessness rejection loneliness hatred fear of committing suicide fear of abandonment insecurity insignificance worthlessness fear of dying fear of hurting loved ones bitterness acceptance depression fear of going to hell fear of losing your mind Other:Other (please specify):Which of the above-listed emotions do you feel are sinful? Why?Concerning your emotions, whether positive or negative, please indicate which of the following best describes you: Readily express my emotions Express some of my emotions, but not all Readily acknowledge their presence, but reserved in expressing them Tendency to suppress my emotions Find it safest not to express how I feel Tendency to disregard how I feel since I cannot trust my feelings Consciously or subconsciously deny them since it is too painful to deal with themIs there someone in your life with whom you could be emotionally honest right now i.e. you could tell this person exactly how you feel about yourself, life and other people?How important is it that we are emotionally honest before God and do you feel that you are? Explain.Please identify any addictions or cravings that cause you difficulty in controlling your intake of sweets, drugs, alcohol, and food in general, etc.:Please identify any moral problems you are dealing with, if anyHave you experienced severe abuse or trauma? Yes NoExplain:Describe briefly your earliest memory. Do you have periods or blocks of time in your past that you can’t remember? Yes NoPlease describe your experiences.Do you spend much time wishing you were somebody else or fantasising that you were somebody else or possibly imagining yourself living at a different time, place or under different circumstances? Yes NoExplain:How many hours of TV do you watch per week? List your five favourite programmes:How many hours do you spend a week reading?What do you read most (newspaper, magazines, books, etc.) and on what topics?What type(s) of music do you listen to, and what is the amount of time spent listening?Would you consider yourself to be an optimist or a pessimist (i.e., do you have a tendency to see the good in people and life, or the bad?) Have you ever thought that maybe you were “cracking up,” and do you currently fear that possibility? Explain.H. Spiritual AreasHave you received Jesus Christ as your personal Saviour? Yes NoWhen did you receive Christ?How do you know that you have received Christ?Are you plagued with doubts concerning your salvation? Yes NoExplain:How do you view God? (Distant? Harsh? Judging? Loving? Near?)Approximately how often do you have a personal Bible reading and prayer time? When and to what extent?Do you find prayer difficult mentally? Explain.When attending church or other Christian ministries, are you plagued with foul thoughts, jealousies or other mental harassments? Explain.Do you regularly attend a local church? Yes NoWhich one?Are there additional ways in which you are enjoying fellowship with other Christian believers? Yes NoWhen and where?Why are you requesting an appointment? Please write a brief paragraph explaining why you are requesting this personal appointment to go through the Steps to Freedom in Christ.F. LifestyleDo you feel there is balance in your life in regard to the following areas: Lifestyle area Spouse Family Friends Work Recreation Christian activity/church Personal time with GodOverall, is there good balance in your life? Yes NoDo you get adequate rest? Yes NoDo you get adequate physical exercise? Yes No Do you primarily eat balanced nutritional meals? Yes NoG. Problem AreasPlease make a list of the problem areas you are dealing with, including any you may have already mentioned in answering the above question. When you are finished, put a check mark by the three items you feel are your greatest areas of need.Remember that this is confidential and you may request to have this inventory returned to you at the time of your appointment (Please don’t use explanations in answering this question, just use only one word or a simple phrase for each item on your list (e.g., anger, difficulty forgiving, depression, guilt, etc.)MY PREPARATION FOR THE FREEDOM APPOINTMENT1. I have read the Freedom in Christ Discipleship Series of books by Steve Goss; Free to be Yourself; Win the Daily Battle; Break Free, Stay Free; The You God Planned. Yes No2. I have completed the Freedom in Christ Discipleship Course. Yes No3. I have read Victory Over the Darkness and The Bondage Breaker by Dr. Neil Anderson Yes No4. If you have not covered the basic teaching, we will usually ask you to do so before we makean appointment. 5. I understand that my participation in completing this Confidential Personal History and inthe Freedom Appointment is totally voluntary on my part and that I am not under anyobligation whatsoever. I understand that the person who will lead me through the Steps toFreedom is not necessarily a professional counsellor or therapist, but a fellow Christian who ismaking himself/herself available to pray with me and guide me through the Steps to Freedom.Therefore I voluntarily ask for this appointment and assume responsibility for my responses asa result of this prayer ministryNext Step – This Confidential Personal History has a double purpose. It is a further preparatorystep for you, by helping you focus on issues to pray about as you go through the Steps toFreedom. It will also help your encourager prayerfully prepare for your appointment. But God maybring more issues to your mind during your appointment. Come ready to be totally openand honest in order to gain the greatest possible help. It is natural to sense your apprehension as you anticipate your appointment, but you willfind an atmosphere of love and acceptance there. If you are ready to proceed, please signour Statement of Understanding: FREEDOM APPOINTMENT STATEMENT OF UNDERSTANDINGThis Freedom Appointment is ran by Bianca L. Gibson, Freedom in Yeshua Ministries. Youshould satisfy yourself as to our credentials, and contact us if you have any concerns about theprocess. Declaration by the person going through the freedom appointment: I understand this is not a counselling appointment, and that the staff of the Ministry statedabove and those associated with them, are not professional or accredited counsellors, normedical or psychological practitioners. I understand that everything I share during this encouragement experience will be keptconfidential and that I alone hold the right to release any information. However, I am also aware that if the staff of the Ministry suspect that a child (under the age of18 years); a vulnerable adult; or an elderly person (over the age of 65 years) is currentlyendangered by abuse; or if I am a danger to myself or others, they will inform the appropriateauthorities, and I give my consent to this. I understand that I am under no financial obligation, I am here voluntarily, and am free to leaveat any time. I deem the persons facilitating this appointment to be encouragers in the Christian faith, andthey are here to help me assume my responsibilities for finding freedom in Christ.DateNameSUBMIT
