The Evaluation

Please give us some information on your life and surroundings: Answer each question or complete each statement by choosing from the drop down box or check box as it would closest relate to you and your current situation.

Your Name

  1. Please identify and describe yourself:
    Sex Male Female
    Hair color
    Eye color

Choose the one that best describes you today: 

If you are married, how long?

Describe your living conditions as close as you can:

With whom do you share your home ? 

Are you currently employeed?

Employers Name:

Choose from the areas below that troubling you most today:

Personal Sickness /   Family Sickness /   Loss of Loved One /   Divorce /   Separation /    Children /   Husband /  Wife /  Financial Worries /   Substance Abuse /   Physical Abuse /   Mental Abuse /   Not Enough Time in The Day! /   Sleeplessness /   Anxiety /   Fear /   Doubting God /  A Feeling of Helplessness /  Anger

Ok, that's it!  Click the submit button and in just a few seconds the results of this questionaire will be displayed on screen  .


Your Email Address: (Required)