Your Name

1. Please identify and describe yourself:

   Age
   Sex	Male Female
   Height
   Weight
   Hair color	Blonde Brown Black Red Gray White
   Eye color	Blue Brown Black Green Gray Violet

Choose the one that best describes you today:  Single Not in A Relationship Engaged Married Divorced Separated

If you are married, how long? Does not apply Less than 3 months Less than 6 months A Year or Less Five Years or Less Seven Years or Less More than 10 Years

Describe your living conditions as close as you can: I Live In The City I Live in The Suburbs Country with Neighbors Close By Country w/ Very Few Neighbors

With whom do you share your home ?  I Live Alone Room Mate Mother & Father Husband Wife Husband & Children Wife & Children Other Family or Friends

Are you currently employeed? Yes No Layed off Self Employeed Student

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

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