Men/Husbands Counseling Questionnaire

Full Name(Required)

Participant Age(Required)

Email(Required)

Phone(Required)

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

Marital Status(Required)

Yes

How Long Have you Been Married?

Do you have children?(Required)

Yes

How many & what are their ages?

Please describe your history with sexual sin, including methods used (i.e. porn, sex with prostitutes, affairs, etc) and the last time you acted out:

Please describe your relationships with your family of origin:

Please describe your efforts to date in searching for recovery (groups, counseling, etc):

Have you had any exposure to or been involved with occult activities?

Have you ever been molested or abused?

Are you on any medications? If so please list the names and diagnosis.

Are you having any suicidal thoughts?

What is your relationship with the Lord like?

When was the last time you had at least one hour of silence with the Lord, alone?

What would you say is your greatest need and/or how we could help you the most?

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