SA Counselling | Wilma Mitchell

1. Full Name:

2. Male / Female?

3. Married / Single / Divorced?

4. Spouses Name:

5. I need assistance in the following areas of my life:

  Marriage
  Relationships
  Work
  Finances
  Religion
  Other

6. Do you have a relationship with the Lord Jesus Christ?

7. Have you accepted the Lord Jesus Christ as your Personal Saviour?

8. What are your biggest problems at the moment?

8. Are you a member of a Church? If so, which Church?

9. Have you endured any traumatic experiences? Explain.

10. Have you been involved with the occult, if so in which way?

11. Were any of your family members ever involved with the occult?

12. Have you ever backslidden? How many times?

13. Do you experience a barrier between you and the Lord Jesus Christ?

14. Do you have a stable relationship with the Lord Jesus Christ?

15. What fears do you have?

16. How would you like to rate your self-confidence out of 1-10 with 10 being 100% self-confident?

17. How would you rate your self-image out of 1-10 with 10 being the most?

18. Have you ever been for psychiatric help?

19. Have you ever been on any anti-depressant medication?

20. Are you addicted to alcohol, drugs etc. If so, for how long and to what extent?

21. Do you watch pornography or child pornography?

22. Do you have problems with controlling anger?

23. Do you play/watch any horrors on a play station, computer, as Dungeons and Dragons etc?

24. Do you or have you worshipped anything else except the Lord Jesus Christ?

25. Have you ever been abused as a child?

26. Do you have any homosexual tendencies?

27. Is your relationship with your parents good or bad?

28. Have you ever been convicted of any criminal offence?