PRIOR TO FILLING OUT THE APPLICATION CONTACT A MOXIE MEMBER AT: ichoosemoxie@gmail.com2 TO 1 Counsel Application(Private and Confidential) CONTACT INFORMATION Name first and last Email Address Date of Birth MM DD YYYY Mailing Address street / city / zip Phone Number (###) ### #### Current Employment or Schooling Preferred Method of Communication email phone text FAMILY INFORMATION Marital Status Single Married Divorced Re-married Widowed Name of Spouse if applicable Number of Children none one two three four five six seven Name and Date of Birth for each child SPIRITUAL INFORMATION Age of Conversion Baptized Yes No How Do You View The Following Persons of the Trinity The Father Jesus Christ The Holy Spirit Do you struggle with anger, confusion, or rejection toward the Father, Jesus Christ, or the Holy Spirit? explain check the box for all that apply to you in regards to your salvation I am a sinner I can approach God as His child All people are sinners My physical health is important Some sins are not forgivable Jesus is God Jesus defeated death My emotional health is important Baptism follows salvation I have received the Holy Spirit God loves me My spiritual health is important Mary is the way to the Father Jesus is the only way to God God chose me I choose me When do you feel at peace with God? My relationship with God is consistent. Strongly Disagree Disagree Neutral Agree Strongly Agree My interaction with God through scripture and prayer is consistent. Strongly Disagree Disagree Neutral Agree Strongly Agree Describe your spiritual health presently: Rate your Fruit of the Spirit: My LOVE is consistent Strongly Disagree Disagree Neutral Agree Strongly Agree My JOY is consistent Strongly Disagree Disagree Neutral Agree Strongly Agree My PEACE is consistent Strongly Disagree Disagree Neutral Agree Strongly Agree My PATIENCE is consistent Strongly Disagree Disagree Neutral Agree Strongly Agree My KINDNESS is consistent Strongly Disagree Disagree Neutral Agree Strongly Agree My GOODNESS is consistent Strongly Disagree Disagree Neutral Agree Strongly Agree My FAITHFULNESS is consistent Strongly Disagree Disagree Neutral Agree Strongly Agree My GENTLENESS is consistent Strongly Disagree Disagree Neutral Agree Strongly Agree My SELF CONTROL is consistent Strongly Disagree Disagree Neutral Agree Strongly Agree Explain why you rated yourself as you did: What are your spiritual gifts: Who is responsible for your spiritual growth? Rate the importance of spiritual growth to you: 1 - 5 ( 1 being not important, 3 somewhat important, 5 very important ) 1 2 3 4 5 EMOTIONAL INFORMATION To the best of your ability, explain your past and present relationships with the following family members. Father: Mother: Siblings: MARRIAGE INFORMATION (if applicable) Number of Marriages: 0 1 2 3 4 5 Current Years Married: Rate the following statments I am satisfied with my marriage: Strongly Disagree Disagree Neutral Agree Strongly Agree I am content with my spouse: Strongly Disagree Disagree Neutral Agree Strongly Agree I am committed to my spouse: Strongly Disagree Disagree Neutral Agree Strongly Agree What is your expectation of marriage? Describe your marriage: CHILDREN INFORMATION (if applicable) What do you believe your responsibility is towards your children? How are your relationships with your kids? What are your strengths as a parent? What are your weaknesses as a parent? Which child do you feel closest to and why? How does your physical, emotional & spiritual health impact your children? BACKGROUND INFORMATION What are your beliefs on the following: Angels: Satan: Demons: Have you had any experiences with any of the following? Ouija Board yes no explain: Psychics yes no explain: Shaman yes no explain: Horoscopes yes no explain: Spirit Guides yes no explain: Astrology yes no explain: Angels yes no explain: Demons yes no explain: Check the following statements that are true about you. I fear: being alone heights men the dark judgment being hurt food rejection losing a loved one crowds doctors night-time driving speaking out love abandonment crowds of people church women death my husband sexuality loss of control the truth strangers dentists children God pain intimacy sickness affection CHURCH INFORMATION (IF APPLICABLE) Name of Church attending: Name of Pastor: Length of time attending: How often you attend: Have you spoken with your Pastor about your current situation? What do you believe to be the responsibility of your church? What do you believe your responsibility is to the church? How do you allow God to use your gifting for the benefit of the Church? How has the church contributed to your Spiritual health/unhealth? What are your views on the church? HEALTH INFORMATION (Physical) The physical chart is optional. However, the more information that we have the better we are able to help you. Include doctors, medications, and diagnosed conditions: HEALTH INFORMATION (Emotional) The emotional chart is optional. However, the more information that we have the better we are able to help you. Include psychiatric visits, medications, and diagnosis How do your physical and emotional conditions affect your spiritual condition? Check the traumas you have experienced: Divorce Molestation Loss of loved one Abandonment Rage Neglect Physical Abuse Substance Abuse Rape Abortion Check the coping mechanisms you turn to: Over eating Lust Sexual immorality Starvation Self-righteousness Lying Greed Rage Filthy Language Criticism Over-spending Sleep Alcoholism Control Homosexuality Judgement Self Discipline Numbness Drugs Gossip Perfectionism Self-reliance Ambition Exaggeration Check the following emotions that dominate your day: Happy Anxious Needy Alone Faith-filled Angry Sad Confused Hurt Hopeless Lonely Overwhelmed Scared Jealous Joyful Fearful Numb Victimized Desperate Hopeful Discontent Other: Check the following emotions will you NOT allow yourself to experience: Happy Stupid Desperate Passionate Sad Angry Needy Anxious Overwhelmed Love Hope Goofy Confused Victimized Thrill Incapable PURPOSE What is your purpose in life? How are you fulfilling this purpose? What keeps you from fulfilling your purpose? CONCLUSION What is your goal from our time together? Review this application... is there anything else you feel we should know about your story? Write a prayer requesting the Lord to join you on this journey: By typing my name below, I have answered this application to the best of my knowledge and ability. This application will be kept Personal & Confidential. A Moxie team member will be responding to your application shortly. PLEASE READ: - By signing this application I understand that the moxie team members sitting with me for 2 to 1 counseling are lay counselors, not professionals. - By signing this application I am acknowledging that I have answered the questions to the best of my knowledge and ability. Your application was delivered, it will be reviewed by a Moxie leader, and they will get back to you.Lastly, if you feel comfortable forwarding on a photo of you and you family to our email it is always helpful when reviewing an application. Please send it to: ichoosemoxie@gmail.com and it will be attached this application.Thank you,Moxie Ministries
