Conflict Resolution Confidential Personal Inventory

Conflict Resolution Inventory (#39)

Please Read Carefully before proceeding

ATTENTION: 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 Information

Name:

Telephone: (daytime)

Age:

Telephone: (evening)

Address

City

State

Zip Code

Occupation:

Present:

Past:

Marital Status:

Single

Married

Divorced

No. of years

Second marriage

Yes

No. of years

Children: names (optional) and ages:

Children in previous marriage: names (optional) and ages:

B. Family History

Were you adopted?

Yes

Were your parents believers (i.e. Christians, “born again”)?

Yes

Were your parents believers (i.e. Christians, “born again”)?

Yes

If so, did they profess and live their faith?

Yes

Were your parents divorced after you were born?

Yes

Who was the authority figure in your home?

Father

Mother

Other

Explain (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

Have your parents, grandparents or great-grandparents ever been involved in any occult, cultic or non-Christian religious practices?

Yes

Explain:

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 the
following:

C. Family Health

Is there a history of ongoing physical illness in your family?

Yes

If Yes, please give specific disease(s)?

Is there a history of mental illness in your family?

Yes

If Yes, please explain briefly

Is there a history of addictive problems in your family?

Yes

If Yes, to what?

D. Physical Health

Describe your general health:

Are you currently under any kind of medication for either physical or psychological reasons?

Yes

Explain: Medication Purpose

Do you have any problems sleeping?

Yes

Describe your sleeping patterns (i.e. Do you have restful sleep?). Are you having any recurring nightmares or disturbances?

E. Thought Life & Emotional Health

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 them

Is 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 any

Have you experienced severe abuse or trauma?

Yes

Explain:

Describe briefly your earliest memory.

Do you have periods or blocks of time in your past that you can’t remember?

Yes

Please 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

Explain:

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 Areas

Have you received Jesus Christ as your personal Saviour?

Yes

When did you receive Christ?

How do you know that you have received Christ?

Are you plagued with doubts concerning your salvation?

Yes

Explain:

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

Which one?

Are there additional ways in which you are enjoying fellowship with other Christian believers?

Yes

When 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. Lifestyle

Overall, is there good balance in your life?

Yes

Do you get adequate rest?

Yes

Do you get adequate physical exercise?

Yes

Do you primarily eat balanced nutritional meals?

Yes

G. Problem Areas

Please 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 APPOINTMENT

1. 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

2. I have completed the Freedom in Christ Discipleship Course.

Yes

3. I have read Victory Over the Darkness and The Bondage Breaker by Dr. Neil Anderson

Yes

4. If you have not covered the basic teaching, we will usually ask you to do so before we make
an appointment.

5. I understand that my participation in completing this Confidential Personal History and in
the Freedom Appointment is totally voluntary on my part and that I am not under any
obligation whatsoever. I understand that the person who will lead me through the Steps to
Freedom is not necessarily a professional counsellor or therapist, but a fellow Christian who is
making 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 as
a result of this prayer ministry

Next Step – This Confidential Personal History has a double purpose. It is a further preparatory
step for you, by helping you focus on issues to pray about as you go through the Steps to
Freedom.

It will also help your encourager prayerfully prepare for your appointment. But God may
bring more issues to your mind during your appointment. Come ready to be totally open
and honest in order to gain the greatest possible help.
It is natural to sense your apprehension as you anticipate your appointment, but you will
find an atmosphere of love and acceptance there. If you are ready to proceed, please sign
our Statement of Understanding:

FREEDOM APPOINTMENT STATEMENT OF UNDERSTANDING

This Freedom Appointment is ran by Bianca L. Gibson, Freedom in Yeshua Ministries. You
should satisfy yourself as to our credentials, and contact us if you have any concerns about the
process.

Declaration by the person going through the freedom appointment:

I understand this is not a counselling appointment, and that the staff of the Ministry stated
above and those associated with them, are not professional or accredited counsellors, nor
medical or psychological practitioners.

I understand that everything I share during this encouragement experience will be kept
confidential 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 of
18 years); a vulnerable adult; or an elderly person (over the age of 65 years) is currently
endangered by abuse; or if I am a danger to myself or others, they will inform the appropriate
authorities, and I give my consent to this.

I understand that I am under no financial obligation, I am here voluntarily, and am free to leave
at any time.

I deem the persons facilitating this appointment to be encouragers in the Christian faith, and
they are here to help me assume my responsibilities for finding freedom in Christ.

Date

Name