Binding Up the Brokenhearted Enrollment

Step #6 – Client Information Questionnaire

Please complete this form to help us get to know you better. The information you share will help your
group leader(s) come better prepared to serve you, understand some of the challenges you may be facing,
and know how to best pray for and support you throughout this study. The information you provide will
only be seen by your group leader(s) and will remain confidential. Nothing written on this form will be
shared within the group unless you choose to share it yourself. At the conclusion of the group, this form
will be returned to you. Thank you in advance for your openness and honest participation.

General Information
  1. Do you have any fears about participating in this Bible study? If so, please explain.
  2. What would you like to accomplish by enrolling in this Bible study?
  3. How did you hear about Healing Hearts Ministries?
Abortion History
* If you have had a surgical or chemical (pill) abortion, please
answer the following questions. If not, you may skip this section.
  1. How many abortions have you had? Surgical: ,
    Chemical (Pill):
  2. How old were you at the time of the abortion(s)?
    #1:
    #2:
    #3:
    #4:
    #5:
    #6:
    #7:
    #8:
    #9:
  3. How far along were you?
    #1:
    #2:
    #3:
    #4:
    #5:
    #6:
    #7:
    #8:
    #9:
  4. Reason(s) for abortion(s) and type of abortion (surgical, chemical, etc.):
    #1:
    #2:
    #3:
    #4:
    #5:
    #6:
  5. As a result of the abortion(s) , what emotional complications have you experienced?
    Guilt/Regret/Remorse
    Fear that others will find out
    Anorexia/Bulimia/Overeating
    Crying/Depression/Sorrow
    Fear of God’s punishment
    Drug/Alcohol abuse
    Suicidal impulses/actions
    Fear of never having children
    Anger/Rage/Hostility
    Despair/Helplessness
    Preoccupation with babies
    Distrust of men/doctors
    Self-hatred
    Obsessive thoughts about baby
    Nightmares/Day terrors
    Anxiety/Panic
    Difficulty making decisions
    Insomnia (inability to sleep)
  6. Briefly describe how you feel about your abortion(s) at this time:
Family History
  1. Are you married, separated, or divorced? If so, how long?
  2. Do you have any children? If so, how many and what are their ages?
  3. If married, how would you describe your relationship with your spouse?
  4. Have you ever had an adulterous affair? If so, when?
  5. Has your husband ever had an adulterous affair? If so, when?
  6. Have any of your parents, grandparents or great-grandparents, to your knowledge, ever been involved in
    any occult, cult, or non-Christian religious practices? If so, what was their involvement?

  7. Briefly explain how your parents felt about spiritual things.
  8. Are your parents currently married, divorced, or separated?
    Married, Divorced
    Deceased: Father: Mother:
  9. Was there a sense of security/harmony in your home during the first twelve years of your life?
    No,
     Yes. Please explain

  10. How did your father treat your mother?
  11. Was there ever an adulterous affair with either your parents or grandparents?
    No, Yes. If yes, who

  12. Were there any incestuous relationships within the family?
    No, Yes. If yes, who was the abuser

  13. Have either your mother or grandmother had abortions?
    No, Yes. If yes, whom?

  14. Are you or any of your brothers or sisters adopted?
    No, Yes. If yes, whom?

Family Health History
  1. Are there any addictive problems in your family history (alcohol, drugs, etc.)?
    No, Yes. If yes, please be specific:

  2. Any history of mental illness? If so, whom?
    No, Yes. If yes, whom?

    What was their diagnosis?
  3. Are there any chronic medical issues or diseases that have been diagnosed for either you or a family
    member? (Some chronic illnesses or diseases such as emphysema, HIV, HepC and diabetes can cause periods
    of emotional anxiety, fear and depression as well as physical pain.)
    Please be specific as possible

  4. When was the last time you had a complete physical examination?
Personal Health History
  1. Do you have any addictions or cravings that you find difficult to control (food, sweets, drugs, alcohol,
    etc.)?
    No, Yes. If yes, please explain:

  2. Are you currently under a doctor’s care for emotional problems?
    No, Yes

    Doctor’s Name:
  3. Are you currently taking any medications?
    No, Yes

    If yes, what kind?
    What are they for?
  4. Are you currently receiving counseling?
    No, Yes

    If yes, from whom?
    Who referred you to this counselor?
    How long have you been seeing this person?
    What is the reason for the counseling?
    If known, what type of counseling? (Biblical, Christian, secular, PTSD)
  5. Are you currently involved in any support or twelve-step groups?
    No, Yes

    If yes, what group(s) are you involved with?
    How long have you been involved?
  6. Do you have any problems sleeping? Are you having any recurring nightmares or disturbances?
    Please explain:
  7. Does your present schedule allow for regular periods of rest and relaxation?
    No, Yes

  8. Have you ever been physically assaulted?
    No, Yes

    If yes, at what age and by whom?
  9. Have you ever been sexually molested/assaulted?
    No, Yes

    If yes, at what age and by whom?
  10. Have you ever been bullied?
    No, Yes

    If yes, at what age and how long?
  11. Were you ever trafficked in any way?
    No, Yes

    If yes, what type, what age and for how long?
  12. Are you struggling with any of the following:
    Daydreaming
    Headaches
    Inadequacy
    Angry thoughts
    Lustful thoughts
    Fantasizing
    Doubts
    Inferiority
    Compulsive thoughts
    Obsessive thoughts
    Dizziness
    Insecurity
    Worry/Anxiety
    Blasphemous thoughts
    		  
  13. Have you ever thought that maybe you were “going crazy” and do you presently fear that possibility?
    No, Yes, If yes, please explain

Military or First Responder Service
* If you have served in the military or as a first responder (Fire,
Police, EMS/Paramedic, Dispatch, etc.), please answer the following questions. If not, you may skip this
section.
  1. Have you ever served in the Military or as a first responder?
    No, Yes

    If yes, which branch, role/agency?
    How many years of service?
  2. If military, were you ever deployed to a combat zone or exposed to combat-related
    situations?
    No,
    Yes,
    Prefer not to answer
  3. If first responder, were you regularly exposed to traumatic or critical incidents (e.g.,
    serious injuries, fatalities, violent events)?
    No,
    Yes,
    Prefer not to answer
  4. Have you ever been diagnosed with any form of Post-Traumatic Stress (PTS) related to your service?
    No,
    Yes, diagnosed through VA/employer,
    Yes, diagnosed by another medical
    professional,
    I suspect I may
    have PTSD or CPTSD, but have not been formally diagnosed,
    Prefer not to answer
Spiritual History
  1. If you were to die tonight, do you know where you would spend eternity?
    No, Yes, Please explain:

  2. 1 John 5:11-12 says, “God has given us eternal life, and this life is in His Son (Jesus, our Savior).
    He who has the Son has the life; he who does not have the Son of God does not have the life.”     Do
    you have a personal relationship with Jesus as your Savior and as the source of your eternal life?
    No, Yes

    If yes, when did you receive Jesus as your Savior?:
  3. Do you read the Bible?
    No, Yes

    If yes, how often?
  4. Do you pray?
    No, Yes, If yes, why?

  5. Do you find it hard to talk to God in prayer?
    No, Yes, If yes, why?

  6. How important is it that you are honest before God, and do you feel that you are?
  7. If you are a Christian, are you plagued with doubts concerning your salvation?
    No, Yes, If yes, please explain:

  8. Are you presently enjoying fellowship with other Christian believers?
    No, Yes, If yes, where and when?

  9. Do you attend a church?
    No, Yes, If yes, what church do you attend? if no, why not?

  10. Do you currently feel unworthy before God?
    No, Yes, If yes, please explain