REGARDING YOUR COUNSELING……………..
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.
REGARDING YOUR QUESTIONNAIRE…………
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
PRE-MARITAL COUNSELING CANDIDATES ONLY
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?
qCreation
qIntelligent
Design
qEvolution
qExtra
Terrestrial
qUnknown
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 ________________________________