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Church Planting Spouse Candidate Confidential Form

We are aware that the following questions are very personal and sensitive. Assessment will not be denied solely based on your responses. We are concerned about unresolved issues in your past. Often these issues, if not resolved, will have a significant impact on your emotional and spiritual life.

This form and information will be kept confidential. Only the Assessment Center’s consulting psychologist will read and it will not remain in your file. You will be consulted in the event there is a need for further clarification. We appreciate your honesty. 
1. Name *This question is required.
2. Do you have any special concerns for your children’s needs? (i.e., health, education, physical needs, emotional, etc.)? *This question is required.
3. Have you ever been convicted of a felony? *This question is required.
4. Do you or have you used tobacco, alcohol, narcotic drugs (including prescriptions), hallucinogens, etc.? *This question is required.
5. Have you ever been involved in any Eastern Religions or occult activities? (i.e., tarot cards, demonism, Ouija boards, T.M., etc.) *This question is required.
6. Have you ever been a victim of abuse, molestation, or rape? *This question is required.
7. Have you ever sexually abused anyone? *This question is required.
8. Have you ever been involved with pornography? *This question is required.
9. Have you ever had pre/extra-marital sexual experiences(s)? *This question is required.
10. Have you ever had a homosexual experience(s) or struggled with homosexual desires?   *This question is required.
11. Are you now or have you been under a physician’s care for mental or emotional treatment? *This question is required.
12. Have you told the truth about all the above statements? *This question is required.
13. If any of these areas are unresolved at this time are you open to getting help with resolution? *This question is required.
15. Signature *This question is required.
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