CONFIDENTIAL PERSONAL INVENTORY
1. PERSONAL INFORMATION 
Name:                                                Email:
Day Phone:                                        Evening Phone: 
Cell Phone: 
[  ] Male [  ] Female                    Age 
Address:  
City State Zip: 
Local Church:  
Are you a member?  
How did you find out about this Community Freedom Ministry? 
Present Marital Status:			If married, how long?  
Ever been Divorced?				If so, how long ago?   
How long were you married before becoming divorced? 
Vocation (Where employed, for what job and when): 
When	Where	What Job	

			

2. FAMILY HISTORY 
A. General 
1. Are you adopted?  
2. Briefly explain your parent’s Christian experience (i.e., were they Christians and did they profess and live their Christianity?).   
3. Are your parents still living?                  If so, are they presently married or divorced?   
4. Was there a sense of security and harmony during the first 12 years of your life? Explain. 
5. Was the father clearly the head of the home or was there a role reversal where the mother ruled the home? Explain. 
6. How did your father treat your mother?   
7. Was there ever an adulterous affair to your knowledge with your parents or grandparents? 
    Any incestuous relationship?  
B. Family Health 
1. Are there any addictive problems in your family history (alcohol, drugs, tobacco, gambling, etc.)?
2. Do you have any addictions or cravings that you find difficult to control?
If yes, please explain.
3. Is there any history of mental illness?        Explain.
C. Moral Climate 
During the first 18 years of your life, how would you rate the moral atmosphere in which you were raised (circle the number): 
Area of Life	Overly 
Permissive	Permissive	Average	Strict 
	Strict Overly	
Clothing	5	4	3	2	1	
Sex	5	4	3	2	1	
Dating	5	4	3	2	1	
Movies	5	4	3	2	1	
Music	5	4	3	2	1	
Literature	5	4	3	2	1	
Free Will	5	4	3	2	1	
Drinking	5	4	3	2	1	
Smoking	5	4	3	2	1	
Church attendance	5	4	3	2	1	

D. Significant Relationships 
List the names of individuals who have had a significant influence on your life including all siblings. Explain briefly why their influence was significant. 
B. Stages in Your Life 
In each of the following stages of your life, give 2-3 adjectives that describe your life during those years. Explain why you felt that Way or what caused those feelings during that time of your life. Write “can’t remember” if you have no memories of that time period.  Write N/A if you have not reached that age range yet.
Pre-school years:

K-grade 2

3rd-6th grade

Junior High (Or middle school) years

High School years

20’s and older

3. HISTORY OF PERSONAL HEALTH 
A. Physical 
1. Are you presently using any kind of medication for either physical or psychological reasons? If so, what medications? 
2. Are you seeing a counselor or therapist at this time?  
If so, how long have you been seeing the counselor? 
If so, how often do you see the counselor? 
3. Have you seen a counselor in the past?   If so, how long ago was that? 
4. Do you have any problems sleeping?       Explain.
5. Are you having any recurring nightmares or disturbances? If so, explain.
6. Does your present schedule allow for regular periods of rest, relaxation and recreation? 
7. Have you ever been physically beaten or sexually molested? Explain. 

B. Mental/ Physical Health 
1. Which of the following are you presently struggling with? 
Headaches		Lustful thoughts		
Dizziness		Blasphemous thoughts		
Lethargy		Compulsive/obsessive thoughts		
Fantasy		Day dreaming		

2. Do you spend much time wishing you were somebody else or fantasizing that you were somebody else or possibly imagining yourself at a different time, place, or under different circumstances? Explain.
3. How many hours of TV do you watch per week?
4. How many hours per week do you listen to music?  List what types you enjoy the most? 
5. How many hours do you spend a week reading?   What do you read primarily? 
6. Do you have regular devotions in the Bible? Describe what you do during your personal devotions? 
7. Do you find prayer difficult? Explain.
8. When attending church or other Christian meetings, are you plagued with foul thoughts, jealousies, or other mental harassments?   Explain. 
C. Emotional 
1. Which of the following emotions are you presently having difficulty controlling?   
Frustration		Feelings of worthlessness		
Anger		Depression		
Anxiety		Hatred		
Loneliness				

2. Which of the above listed emotions do you feel are sinful? Why?
    
3. Fear is a common emotion that is often not recognized or acknowledged. Please check any of the following fears you are currently experiencing. 
Fear of death  		Fear of never getting married 		
Fear of never being loving or being loved		Fear of going crazy		
Fear of Satan		Fear of confrontation		
Fear of embarrassment		Fear losing salvation		
Fear of failure		Fear of God not loving you		
Fear of being victimized		Fear of having committed the unpardonable sin 		
Fear of rejection		Fear of specific individuals (name them)		
Fear of disapproval 		Fear of becoming/being homosexual 		
Fear of financial problems		List any other specific fears not listed		
Fear of future 		Fear death of loved one 		
Fear of being a hopeless case 		Fear of divorce		
Fear of marriage 				

4. Concerning your emotions (whether positive or negative) which of the following best describes you? 
	Readily express emotions	
	Readily acknowledge their presence but reserved in expressing emotions	
	Tendency to suppress or deny my emotions	
	Find it safest not to express howl feel	
	Tendency to disregard how I feel since I cannot trust my feelings	

5. Who in your life can you be emotionally honest with right now? (i.e., you can tell this person exactly how you feel).
6. How important is it that we are emotionally honest before God and do you feel that you are? Explain: 

4. SPIRITUAL HISTORY 
A. If you were to die tonight, do you know where you would spend eternity? (That is, would you say you are 25%, 50%, 75% or 100% sure that you are going to heaven?)
B. Suppose you did die tonight and appeared before God in heaven, and He were to ask you, “Why should I allow you into My heaven?” How would you answer Him? 
C. 1 John 5:11, 12 says, “God has given us eternal life, and this life is in His Son. He who has the Son has the life; he who does not have the Son of God does not have the life.” 
1. Do you have the Son of God living in you?
2. When did you receive Him (John 1:12)?
3. How do you know that you have received Him?
D. Are you plagued with doubts concerning your salvation?
E. Are you presently enjoying fellowship with other believers and, if so, where and when?
F. Are you under authority of a local church where the Bible is preached and do you regularly support it with your time, talent, and treasure? If not, why not?