Health Assessment [COI]
Confidential Information:
We realize that these questions are personal and may be sensitive. In each of these areas we acknowledge the forgiveness and healing that comes through Christ. However, due to the effects of being fallen and living in a fallen world, it is important to evaluate the impact of these issues on your emotional and spiritual life in relation to ministry with Campus Outreach. Please do not assume that any information you provide will automatically disqualify you for service. This information will be treated with strictest confidence. You will be consulted if there is the need for this information to be shared with anyone other than the CO personnel. The only people who will read this section are the Regional Director and Board Members.
Name
*
First Name
Last Name
Email
*
example@example.com
Gender
*
Please Select
Male
Female
1. Do you have financial responsibilities for parents, grandparents, or anyone else? If married, other than your spouse.
*
No
Yes
Yes and my spouse is aware of this
2. Are you in financial debt?
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No
Yes
Yes and my spouse is aware of this
If you have debt, approximately how much?
*
3. Have you been convicted of a crime other than minor traffic violation?
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No
Yes
Yes and my spouse is aware of this
If you answered yes to question 3, please explain.
4. Aside from pre-marital counseling, have you ever received counseling from a pastor, counselor, psychologist, psychiatrist, etc.?
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No
Yes
Yes and my spouse is aware of this
If yes to question 4, please explain.
5. In the past four years, have you abused alcohol, narcotic or prescription drugs, hallucinogens, etc.?
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No
Yes
Yes and my spouse is aware of this
If yes to question 5, please explain.
6. Have you ever had suicidal feelings or thoughts?
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No
Yes
Yes and my spouse is aware of this
If you answered yes to question 6, please explain.
7. Have you ever been a victim of physical or verbal abuse, molestation or rape?
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No
Yes
Yes and my spouse is aware of this
If you answered yes to question 7, please explain.
8. In the past six months, have you struggled with viewing pornographic material?
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No
Yes
Yes and my spouse is aware of this
If you answered yes to question 8, please explain.
9. Have you ever had an extra-marital sexual experience(s)?
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No
Yes
Yes and my spouse is aware of this
If you answered yes to question 9, please explain.
10. Have you ever participated in "sexting," a sexual chat room, or any other form of sexual video chatting?
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No
Yes
Yes and my spouse is aware of this
If you answered yes to question 10, please explain.
11. Have you ever had an abortion?
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No
Yes
Yes and my spouse is aware of this
If you answered yes to question 11, please explain.
12. Have you ever struggled with an anorexia nervosa, bulimia, or another eating disorder?
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No
Yes
Yes and my spouse is aware of this
If you answered yes to question 12, please explain.
13. In the past four years, have you had a homosexual experience(s) or struggle with homosexual desires?
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No
Yes
Yes and my spouse is aware of this
If you answered yes to question 13, please explain.
14. Have you ever been involved in the physical abuse of a child or another adult?
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No
Yes
Yes and my spouse is aware of this
If you answered yes to question 14, please explain.
15. Is there any past action of yours which would cause anyone to question your qualifications for Christian ministry?
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No
Yes
Yes and my spouse is aware of this
If you answered yes to question 15, please explain.
Signature
To the best of my knowledge the information included on this form is true and I have not withheld any information that might affect the evaluation of my ability to fulfill the job description for ministry with Campus Outreach.
*
Name
*
First Name
Last Name
Submit
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