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Personal History Questionnaire
Please be sure to sign the RiCM Prayer Ministry Agreement before completing this questionnaire. This questionnaire will take time and may bring up many emotions. Pray before you begin and while you are completing it.
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Your Name
*
Your answer
Your Mailing Address
*
Your answer
Telephone Number
*
Your answer
Email Address
*
Your answer
Highest level of education completed?
*
Some high school
High school graduate/GED
Some college
Associates degree
Bachelors degree or higher
Sex
*
Female
Male
Prefer not to say
Age
*
Your answer
Do you have siblings? Please check all that apply.
*
Older brothers
Older sisters
Younger brothers
Younger sisters
Required
Were you adopted?
*
Yes
No
Were you brought up by someone other than your parents?
*
Yes
No
If you responded yes, please explain below.
Your answer
Did your parents want you?
*
Yes
No
If you responded no, please explain below.
Your answer
Is it likely your parents were fighting while you were in the womb?
*
Yes
No
If you responded yes, please explain.
Your answer
Was there a sense of security and harmony in your home during the first 12 years of your life?
*
Yes
No
If you responded no, please explain below.
Your answer
How was authority exercised in the home? Which parent was in charge and how did he or she operate?
*
Your answer
How was affection shown between your parents and toward you?
*
Your answer
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