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Please print this text and forward it to Pastor Joe via email or hard copy prior to your first counseling session. Thank you!



As your counselor, I promise to keep all information that is spoken or documented in our conversations in strict confidence. If I speak to either of you individually, apart from the other, I will not share any part of those conversations with your potential spouse unless you so direct me to do so. I will not share any documents you or I create with the other person unless you so direct me. The only way that any information will be shared is in the case where someone’s personal safety or life may be at risk by the withholding of that information from the proper parties and authorities.




Please answer the questions as accurately as you possibly can. When you complete the questionnaire you may check as many answers for each question that are applicable. If you are not comfortable or are not ready to answer any of the questions at this time, please do not feel any obligation to do so. Your answers are not designed to disclose facts but rather to be used to develop a psychological and cognitive picture of who you are. The more accurate and honest that you answer these questions, the more helpful I can be in the counseling process. Please remember that your answers will not be shared with anyone unless you so direct them to be, and your answers will not be directly or openly discussed in the counseling sessions unless you expressly desire them to be.


Please select only one answer from the following two questions



I want to get married because I am

qin love with my potential spouse

qfalling in love with my potential spouse

qlearning how to love my potential spouse


I consider a successful marriage as one ……………

qthat yields a happy family and a successful social life

qwhere both spouses love each other and are happy

qfounded in mutual trust and respect


Please answer the following statements using any answer(s) that are applicable. You are not required to answer all of the questions if you do not wish to.   


I was raised 

__as a protestant Christian                                       __as a Roman Catholic

__as a Greek or other Orthodox Christian               __as a Orthodox Jew

__as a Conservative Jew                                          __as a Reformed Jew

__as a Muslim                                                          __as a Hindu

__as a Buddhist                                                        __as a _____________

__with no religious preference                       


I consider myself to be 

__a protestant Christian                                              __a Roman Catholic

__a Greek or other Orthodox Christian                      __a Orthodox Jew

__a Conservative Jew                                                 __a Reformed Jew

__a Muslim                                                                 __a Hindu

__a Buddhist                                                               __a _____________

__with no religious preference                        


I was raised

__in a financially conservative home    __in a financially moderate home     __in a financially liberal home


I was raised

__in a politically conservative home     __in a politically moderate home       __in a politically liberal home


I consider myself to be 

__financially conservative               __financially moderate                        __financially liberal


I was consider myself to be

__politically conservative                __politically moderate                        __politically liberal


I was educated

__in the public school systems              __in a private / parochial school

__in a home-school environment          __in some public and some private schools

__in some home-school and some private schools        __in some home-school and some public schools   


I have completed

__High School                            __1 year of college

__2 years of college                    __4 years of college (no degree)

__4 years of college degree in _____________________

__some Masters studies

__Masters Degree in ____________________________

__Some doctoral studies

__Doctorate or Ph.D. in______________________________


My parents

__never fought in front of me         __were always fighting in front of me

__only raised their voice occasionally         __always went away by themselves to settle disagreements


My Parents

__were never violent                                    __were somewhat violent

__were only violent towards each other       __were only violent at their children

__were only violent towards outsiders


My Parents

__were typical parents                           __were somewhat reserved socially

__were very reserved socially               __were very outgoing socially

__were “off and on again” in their social life


My siblings

__were never violent                                     __were somewhat violent

__were only violent towards each other        __were only violent at other children

__were only violent towards our parents


My physical appearance

__is very important to me               __is somewhat important            

 __is not important


What others think of me 

__is very important to me               __is somewhat important            

__is not important




I would like to live

__until I am 100 (or more)                   __until I am 70

__until I am 50                                     __until I am__________


I  consider myself to be

__a victim of verbal abuse                __a victim of psychological abuse  

__a victim of sexual abuse               __a victim of sexual harassment

__a victim of my circumstances      __a victim of a bad up-bringing

__a victim of very strict parents       __not applicable 


I consider myself to be

__an abuser of prescription drugs     __an abuser of illegal or recreational drugs

__a user of marijuana                        __an alcoholic

__a casual drinker                             __a social drinker only

__addicted to food                             __addicted to sexual activity

__addicted to pornography                __addicted to illegal drugs

__addicted to extreme activities (adrenalin rush)    __not applicable



I am embarrassed

__by others who display emotional outbreaks?

__by rude and thoughtless people?

__by poor people?

__by others who do not display their emotions?


I am angered

__by others who display emotional outbreaks

__by rude and thoughtless people

__by poor people

__by others who do not display their emotions


I try to avoid

__people have done harm or wronged me in the past

__people who I suspect have done wrong or harmed me in the past

__people who I suspect don’t like me

__people I disagree with

__people I think are very attractive

__people who look odd or different 


How important are your emotional expressions to you?

__not very important

__somewhat import

__very important

__extremely important


How important are other people’s emotional expressions to you?

__not very important

__somewhat import

__very important

__extremely important


What age group of people are you most comfortable with socially?

__5-11        __12-15        __16-19       __20-25      __25-35      __35-48

__49-55      __56-70        __70 & older


What age group of people are you least comfortable with socially?

__5-11        __12-15        __16-19       __20-25      __25-35      __35-48

__49-55      __56-70        __70 & older



Place a number “1” beside the statement that best describes the closest description of your personal life evaluation. Place a “5” beside the one that is the least descriptive.


____“My success is where I always have been, and where I always will be”

____“I’m where I want to be and nothing else really matters now.”

____“I knew if I worked hard enough I could get what I wanted all along.” 

____“I never really thought I could be this successful”

____ “There must be an easier way than the way I am going” 

____“If I work hard enough I can accomplish anything”

____“I guess I’m going to have to do it a certain way to get what I want.”

____“I want what I want, and I’ll do what I have to do to get it.”

____“I want it and you’re going to give it to me.”

____“I’m living in a prison, and I don’t like it”


Please complete the following  mentality type test. Using the following gauge: 1 = not at all 2= very rarely 3= don’t know 4= usually so 5 = extremely so. Write the number in the box at the end of each question that describes you personally. Please try to avoid using the number “3” as much as possible.  


1).  I find great satisfaction in completing basic tasks.  q

2).  I feel needed when I am listening to others talk about their problems. q

3).  I think it is interesting to see how mechanical things function. q

4).  I would like to have many careers in my lifetime. q

5).   When things slow down, I get bored and/or frustrated. q

6).   I display my emotions very easily. q

7).   Numbers and/or statistics are very interesting to me. q

8).   I could make traveling into a career. q

9).   I like to take on projects I can do all by myself. q

10). I have learned a lot from my personal history. q

11). I enjoy learning what others are thinking about. q

12). I like to think “outside the box”. q

13). Obtainable goals are a very necessary part of my life. q

14). It is easy for me to be happy when others around me are happy. q

15). I enjoy solving riddles and puzzles. q

16). I need to examine all the possibilities in a situation. q 

17). I like to coordinate others to work in harmony together. q

18). I feel a need to be an influence on others. q

19). I am, or could be a perpetual student/learner. q

20). I often think that there has to be a better way to do or perceive things. q

21). I like to be in charge in most arenas of my life. q

22). Sometimes I am sad for no apparent reason at all. q

23). I utilize checklists and schedules to help me accomplish things. q

24). I have a very active imagination and thought life. q 


Please select the answer that best fits your world view.


Where did I come from? 


qIntelligent Design


qExtra Terrestrial



Why am I here?

qFor a specific purpose/career/end result

qTo reach my goals

qTo be an object of and projection of affection

qTo serve and satisfy others


How am I going to live my life? 

qUnder the guidelines of established right from wrong

qTreating others as I desire to be treated

qDefining truth as it is relative to me

qDefining truth as it is absolute in the world

qPursuing and enjoying healthy environments


Where am I going?

qFatalist – I believe there is nothing beyond this mortal life

qReincarnation- I believe I will come back as another person or a different life form.

qReinhabitation – I believe cryogenics is a definite possibility and will pursue it.  

qEternal existence – I believe in an afterlife that is spiritually connected to this life

qUnknown or Other _______________________________________________  


Do you have any questions that you would like to be addressed in the counseling process?





I have answered the questions to the best of my knowledge and level of comfort.

NAME ___________________________

SIGNATURE _________________________

DATE _________  PHONE________________________

TEXT? qYes qNo

EMAIL ________________________________