Spiritual Roots Diagnostic Survey (Part 1)
A christian assistance guide for persons with spiritually rooted problems
Your name:
*
First Name
Last Name
E-mail:
*
Your email address is needed in order to respond to your submission
E-mail address of MTL:
Optionally you can add the email of your Ministry Team Leader and he will a receive a copy of this form as well
Phone Number:
-
Area Code
Phone Number
Back
Save & go to the next page
Save
Personal Details
Birth Date
*
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a year
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
Year
Gender:
*
Female
Male
Occupation:
I grew up with my biological parents
Check if answer is 'yes'
Rate your parent's marriage:
*
1
2
3
4
5
6
7
8
9
10
Worst
Best
1 is Worst, 10 is Best
If they separated or divorced, how old were you?
Describe all traumatic incidents from your childhood years until today:
Age
Abused (emotionally)
0-5 years
6-12 years
13-18 years
19-current
Abused (verbally)
0-5 years
6-12 years
13-18 years
19-current
Abused (physically)
0-5 years
6-12 years
13-18 years
19-current
Accident (involved in)
0-5 years
6-12 years
13-18 years
19-current
Death of loved one
0-5 years
6-12 years
13-18 years
19-current
Domestic violence - victim
0-5 years
6-12 years
13-18 years
19-current
Domestic violence - witness
0-5 years
6-12 years
13-18 years
19-current
Molested
0-5 years
6-12 years
13-18 years
19-current
Raped
0-5 years
6-12 years
13-18 years
19-current
School boarding house
0-5 years
6-12 years
13-18 years
19-current
Add events not listed above (if necessary):
Back
Save & go to the next page
Save
Educational and Marital Background
Highest school qualification:
*
Please Select
Grade 12
Grade 11
Grade 10
Grade 9
Grade 8
Grade 7
Grade 6
Grade 5
Grade 4
Grade 2
Grade 1
None
Tertiary qualifications and other training:
Marital Status:
*
Please Select
Single
Married (hetero)
Married (same-sex)
Married (bigamist - traditional)
Seperated
Divorced
Live together
Widower
This is Marriage nr:
Back
Next
Save
Marital Background
Name of spouse:
Occupation of spouse:
If you ever separated, when did it happen?
If needed, will your spouse agree to participate in counselling?
*
Please Select
Yes
No
Back
Next
Save
Children:
Name
Age
Gender
Out-of-wedlock(Y/N)
Adopted (Y/N)
1.
2.
3.
4.
5.
History of miscarriages:
History of stillborns:
History of abortions:
History of infant deaths:
Back
Save & go to the next page
Save
Counselling / Medical Treatment Background
Details of any current medical treatment:
If you ever used drugs for any NON-MEDICAL REASON (e.g. addictions) give details:
Drug
Year
Period
Frequency
1.
2.
3.
4.
5.
If you needed to use prescription drugs for EMOTIONAL REASONS, give details:
Drug
Year
Period
Reason
1.
2.
3.
4.
5.
Will you agree to a medical examination if deemed necessary?
*
Please Select
Yes
No
Give details of counselling, therapy or psychological treatment:
Name of person/institution
Type (councelling/therapy/psychological)
Year
Period
Reason
1.
2.
3.
4.
5.
Back
Save & go to the next page
Save
Religious Background
Religious Group
*
Please Select
Christian - Pentecostal
Christian - Roman Catholic
Christian - Traditional
Christian - Other
Non-Christian
Back
Next
Save
Christian Background:
Name of church or religious group:
Give a concise background of your church/religious history:
Faith group/Church
Year from
Year to
1.
2.
3.
4.
5.
Why do you say you are a Christian?
Please Select
I grew up in a Christian home
I accepted Jesus Christ as my Saviour
I attend a Christian church regularly
N/A
Were you ever baptised?
Please Select
No
As a baby
By submersion after being born again
As a baby and after being born again
Rate your current relationship with God:
1
2
3
4
5
Daily Bible reading:
1
2
3
4
5
6
7
8
9
10
Not at all
More than once a day
1 is Not at all, 10 is More than once a day
Daily Prayer Time:
1
2
3
4
5
6
7
8
9
10
< 1 min a day
> an hour daily
1 is < 1 min a day, 10 is > an hour daily
Back
Save & go to the Submit page
Save
Thank you!
This is all the information. Click on the Submit button to submit the form and to proceed to Part 2 of the survey.
Save
Submit the form
Should be Empty: