Operation Reset Intake Questionnaire

Intake Questionnaire

Please take your time completing this form. It is lengthy, and should not be completed all in one sitting. When you are ready to take a break, please save it and you will be prompted to create a free account. You can pick up where you left off at a later time. The more information you provide, the deeper freedom you will receive.
Name:
Email
example@example.com
Age:
Are you a born again Christian?
At approximately what age?
Prior marriages?
If so, how many?
Names of Children:
Are your parents divorced?
If yes, how old were you?
Were you the firstborn?
Relationship Status:
Rate your level of stress at work (1=Extremely low to 10=Extremely high)
Rate your level of stress in your family (1=Extremely low to 10=Extremely high)
Rate your level of stress in your social life (1=Extremely low to 10=Extremely high)
Rate your level of stress in finances (1=Extremely low to 10=Extremely high)
Rate your level of stress with your health (1=Extremely low to 10=Extremely high)
Section I: Family Data- Parents & Siblings

In order for me to get to know you better, I will have to ask you some questions about how you were raised. Things like the family atmosphere, your parent’s relationship, sibling relationships what expectations were put on you, cultural/religious customs, etc. Please be as forthright as possible so that we can uncover as many things as possible holding you back from reaching your full God ordained potential.
What was your mother's age at the time of your birth?
Please share adjectives to describe her. What kind of mother was she to you growing up?
What was your father's age at the time of your birth?
Please share adjectives to describe him. What kind of father was he to you growing up?
Were they married when you were conceived?
Were they ever married?
How was their relationship? Any major conflicts? If you have never seen or heard about their interaction, put N/A.
Moving onto your siblings- Please share your siblings names, gender and their age. Only include siblings that were in your home during the time YOU were between the ages 0-7. Please list them from oldest to youngest, including yourself. Also, please include adjectives to describe their personality. (Example: Brian, Male, 23, shy, self-conscious, studious.) If you are an only child, put N/A.
Which sibling was most different from you? If you are an only child, put N/A.
Which sibling was most like you? If you are an only child, put N/A.
What was/is your role in the family?
Section II: Household Environment

In this section, I will ask you questions about the climate of your household at the time you were between ages 0-7. This will help me to get an idea of what it was like to grow up in your home, and how this may be impacting you now.
What were your family’s most important values?
Which sibling had the closest relationship to your mother? If none, put none or N/A.
Which sibling had the closest relationship to your father? If none, put none or N/A.
Which parent were you closest to?
Which parent had the final say with decisions?
What were the expectations put on the children?
What was the overall mood of the household?
Any sickness/death in the home during this time? If so, who?
How many times did your family relocate while you were between 0-16 years of age?
What was your religion?(From ages 0-7) Have you practiced any other religions?
What was your family’s involvement in religion? (From ages 0-7)
Section III: Client Developmental Data

During this phase of the questionnaire, I will ask you some questions about yourself from ages 10-18 . Note: It is not necessary to go into great detail with any of your responses IN THIS SECTION. Ask the Holy Spirit to show you any areas of concern. He will tell you!
What kind of student were you (ages 10-18)?
What was your school behavior like (ages 10-18):
What expectation did you have for yourself as a child? (Ages 10-18)
What were your goals as a child? What did you daydream about?
What were your religious convictions? (Ages 10-18)
Did you ever want to be the opposite sex?
What was your relationship with adults/ authority? (Ages 10-18)
Are you aware of any trauma you might have experience during your mother’s pregnancy or delivery? Accidents, divorce, spoken words such as “We shouldn’t be having this child”, etc. Were you a full-term baby? Was there anything wrong with you when you were born? (Ex: Jaundice) If none, put N/A
Are (were) there any other significant problems in the home? If so, please explain further.
Section IV: Early Memories (EM)

In this section you will be asked to share a few early memories of yourself. These memories should be a vignette- so it should have a beginning, middle, and an end. It should have a visual quality so you should be able to see these memories in your mind (not just hear them). These memories should be between the ages 0-7 preferably. If you are unable to remember anything from that far back, share any memories you have as a child. They should be short stories. Before you begin, please take a second to ask the Holy Spirit to bring only those memories to mind that he wants you to share.
EM Example:

Age: 5 E.M. I was playing school with a few of my cousins and I finished my work first and turned it in. My older cousin read all my mistakes to my other cousins and they all laughed at me. It was a joke but it hurt my feelings. If you had to take a picture of the exact scene that was the focus of the E.M what would it be? My older cousin telling my other cousins that my work was wrong. Feelings: Sad, embarrassed. Why did you feel this way? Because everyone thinks I am not smart. Most important part of the E.M: My cousin betraying me.
EM # 1: Age
EM # 1: Explain the memory here.
EM # 1: If you had to take a picture of the exact scene that was the focus of the EM, what would it be?
E.M. # 1: Feelings?
E.M. # 1: Why did you feel this way?
EM # 1: Most important part of the E.M?
EM # 2: Age
EM # 2: Explain the memory here.
EM # 2: If you had to take a picture of the exact scene that was the focus of the EM, what would it be?
E.M. # 2: Feelings?
E.M. # 2: Why did you feel this way?
EM # 2: Most important part of the E.M?
Any recurring childhood dreams? Any recurring adult dreams? If none, put N/A
Any movies or TV programs that are/were particularly frightening to you, or specific scenes that seem to stick in your memory? If none, put N/A
Do you recall any spoken words from parents or others that were condemning: For example, “you’re fat”, “you’re stupid”, “you’ll never amount to anything”, “you always mess up”, “I don’t know why I had you (or these kids)”, “you can’t be in our group”, etc. If none, put N/A
Any sexual abuse or sexual embarrassment through childhood?
Any physical abuse from parents or others?
Did you experience any embarrassing or humiliating experiences at school or from a teacher? If none, put N/A
Do you have difficulty trusting others?
Have you participated in pre-marital sex?
Please list accidents or injuries that come to your mind as being frightening to you during childhood? Type N/A if nothing comes to mind.
Movies or TV programs that were particularly frightening to you, or specific scenes that seem to to stick to your memory. Type N/A if nothing comes to mind.
Have you participated in extra-marital sex?
Have you been exposed to pornography? If yes, how old were you when you had your first exposure? If none, put N/A
Any period of habitual immorality? (including pornography, sexual fantasy, promiscuity, etc? If none, put N/A
Section IV: Generational Data

All questions relating to family apply to your entire family - even generations back.
Please check any area of family or generational involvement in any of the following practices. This includes your entire family (Grandparents, aunts, uncles, cousins, etc.)
If you answered yes to any of the above, please explain:
History of Alcohol Addiction?
History of Drug Addiction?
History of Food Addiction?
History of Nicotine Addiction?
History of Medicine Addiction?
History of Social Media Addiction?
Any other addictions? This includes masturbation, gambling, coffee/caffeine, sex, shopping, vaping, TV, pornography, sports, exercise, etc. Please clarify - me, family, or both. If none, put N/A
Please answer the following questions as they apply to your life:
Have you been diagnosed, at any time by a doctor? If yes, please list diagnoses here. If none, put N/A:
Please list surgeries and approximate age. If none, put N/A:
Do you have inexplicable pain with no medical explanation for it? If yes, explain.
Do you feel like you have an eating disorder?
Do you or anyone in your family suffer from any of these ailments?
Other Medical Ailments:
Any repetitive behaviors in your family? (early death/accidents, bitterness, poverty, etc.) If none, put N/A.
Were you ever diagnosed with a learning disability?
Have you ever had suicidal thoughts?
Has there been a death of someone close to you?
If so, whom?
What are you afraid of?
Any involvement in any way (even if you were a bystander) with Oiji Boards, Magic Ball, Levitation Games, Seances, Fortune Tellers, Trot Cards, Astrology, Horoscopes, Fascination with books about magic, physics seers, etc.
If so, please explain.
Do you have any objects in your home or possession that relates to ungodliness or cults? This includes new age religions such as books about eastern deities, crystals, heavy metal music, Native American/African artifact, sage for healing, items connected with other religions or rituals, Wiccan or other occult items? If yes, please explain. If none, put N/A
Do (did) you have nightmares?
Do you hear voices?
If yes, please expound or give an example:
Did you have an imaginary friend as a child?
If yes, what were their names?
Have you ever "felt" a presence in the room?
If yes, please explain:

Please answer the following:

Rows	What energizes you?	What de-energizes you?	Who energizes you?	Who de-energizes you?
1.
2.
3.
4.

Starting with your earliest memories, share key people, places, and events in your life, both painful and joyful. These events and characters would definitely be in your biopic movie.

Rows	Joyful Memories	Age	Painful Memories	Age
1.
2.
3.
4.
5.
6.

If you have used DNA analysis services before (Ancestry.com, 23 and Me, etc.), please upload your report here. We will use it to find buried curses along your genetic bloodline.

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Is there any additional information that you think we should know to help you on your journey toward total healing? If none, put N/A
Should be Empty:

Intake Questionnaire

Section I: Family Data- Parents & Siblings

Section II: Household Environment

Section III: Client Developmental Data

Section IV: Early Memories (EM)

EM Example:

Section IV: Generational Data