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Survey of Previous Marriage(s) For the purpose of this survey prior cohabitation will also be considered as a marriage. Each marriage or cohabitation will be recorded on separate survey forms. Marriage # __ of __ Ages and date at time of marriage SPOUSE ___ YOU ___ Date _____________ In cases of cohabitation these figures are given from when cohabitation began. Name of spouse _________________________________ Spouse education level _________________ Was the above person married before? (ึ) Yes ___ No ___ cohabited with another Yes ___ No ___ Location of meeting ________________ญญญ___________________________________________________ Marriage domicile _____________________________________________________________________ Occupation of spouse __________________________________________________________________ Your Occupation ______________________________________________________________________ Did the spouse bring children into the union? (ึ) Yes ___ No ___ If so, how many? ___ If some did not live with you as the primary residence, please indicate so in the information about them you give below. Did you bring children into the union? (ึ) Yes ___ No ___ If so, how many? ___ Did all of your children live with you in this new marriage as their primary residence? (ึ) Yes ___ No ___ The counselor will be asking about these children in a counseling session following your completion of the survey. The information you provide here will make it possible for him to do an effective job when you get together to cover this vital subject. If the person you wed or lived with brought children into the union answer the following about the children beginning with the oldest. If more lines are needed, continue to answer the same questions for the remaining children on the back of this page. If this is necessary alert your counselor by darkening this . Name __________________________ gender Male Female age at time of union ____ Describe this child's attitude/relationship toward you. ____________________________________________________________________________________ ____________________________________________________________________________________ Name __________________________ gender Male Female age at time of union ____ Describe this child's attitude/relationship toward you. ____________________________________________________________________________________ ____________________________________________________________________________________ Name __________________________ gender Male Female age at time of union ____ Describe this child's attitude/relationship toward you. ____________________________________________________________________________________ ____________________________________________________________________________________ If you have thought of something the counselor needs to know at this point, blacken this � and write the information on the back of this page. Survey of Previous Marriage(s) page 2 In this survey, you will be asked questions of a sensitive nature. This is necessary because the information is important to helping you. Because the space is limited the survey cannot explain every facet of why a question is being asked. You are being asked to answer these questions based on the same sort of trust you would give to any other professional such as a medical doctor, but also with the awareness that the Christian Counselor has great respect for your person as someone created in the image of God. However, any question you find of particular concern or unsettling you should discuss with the counselor. Now we need to ask about children you brought into the marriage, if any. If this does not apply to you move on to the next set of questions. Answer the following about the children beginning with the oldest. If more lines are needed, continue to answer the same questions for the remaining children on the back of this page. If this is necessary alert your counselor by darkening this . Name __________________________ gender Male Female age at time of union ____ Describe this child's attitude/relationship toward you or your spouse. ____________________________________________________________________________________ ____________________________________________________________________________________ Name __________________________ gender Male Female age at time of union ____ Describe this child's attitude/relationship toward you or your spouse. ____________________________________________________________________________________ ____________________________________________________________________________________ Name __________________________ gender Male Female age at time of union ____ Describe this child's attitude/relationship toward you or your spouse. ____________________________________________________________________________________ ____________________________________________________________________________________ Name __________________________ gender Male Female age at time of union ____ Describe this child's attitude/relationship toward you or your spouse. ____________________________________________________________________________________ ____________________________________________________________________________________ If you have thought of something the counselor needs to know at this point, write the information on the bottom of this page. ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Survey of Previous Marriage(s) page 3 Did you and the person on this page have children together? ึ Yes ___ No ___ If yes, how many? ___ Answer the following about the children beginning with the oldest. If more lines are needed, continue to answer the same questions for the remaining children on the back of this page. If this is necessary alert your counselor by darkening this . Name __________________________ gender Male Female age at time of divorce ____ Describe this child's attitude/relationship toward you and spouse. ____________________________________________________________________________________ ____________________________________________________________________________________ Name __________________________ gender Male Female age at time of divorce ____ Describe this child's attitude/relationship toward you and spouse. ____________________________________________________________________________________ ____________________________________________________________________________________ If you have thought of something the counselor needs to know at this point, blacken this � and write the information on the back of this page. It is important that you write about any conflicts or discipline problems with children. If you have omitted to record this on the lines below each children's names please go back and do so now. The relationships of the children to each other is important. They fall into different categories which we will ask you about now. You may have problems with this section of the survey. If you do, ask the counselor and he will help you work through it. Did the children belonging to the person you married have conflicts with each other? ึ Yes ___ No ____ If the answer to the above question is answered with a yes, describe those conflicts on a separate sheet of paper. It should be attached to the back of this page. Did the children belonging to you have conflicts with each other? ึ Yes ___ No ____ If the answer to the above question is answered with a yes, describe these conflicts on a separate sheet of paper. It should be attached to the back of this page. Did the children belonging to you jointly have conflicts with each other? ึ Yes ___ No ____ If the answer to the above question is answered with a yes, describe these conflicts on a separate sheet of paper. It should be attached to the back of this page. Were there conflicts between any of the separate sets of children? ึ Yes ___ No ____ If your answer was yes, did these conflicts include whole sets or individuals ? Please blacken the correct response and describe the conflict on a separate set of paper to be attached to the back of page. This marriage ended in annulment divorce death after _______ years in the year _____________ The next several questions explore the relationship between you and the other person in this marriage. They are somewhat delicate in nature, but necessary to your counselor being able to help you. Was you marriage consummated ึ Yes ___ No ____ (Note: If you were involved together sexually prior to marriage, you cannot consider the marriage properly consummated, and should mark no.) If your answer was no due to prior sexual knowledge blacken this square If your answer was no due to medical concerns blacken this square If your answer was no due to some other problem blacken this square Survey of Previous Marriage(s) page 4 Was there a delay in the consummation of your marriage? ึ Yes ___ No ___ If you marked yes and the delay was due to some circumstance such as proxy marriage mark If you marked yes and the delay was due to medical/physical reasons mark If you marked yes and the delay was due to emotional reasons mark If the marriage was marked by physical abuse mark here Did physical abuse begin before or after marriage? If physical abuse began after marriage, please say approximately how long after ________________________________________________________ If the marriage was marked by arguing or squabbling mark here Did this begin before or after marriage? If arguing or squabbling began after marriage, please say approximately how long after ______________ Some common sources of friction are given below. Please mark all that apply. (Note, potential problems with children brought into a marriage have already been thoroughly explored.) Family concerns (parents or siblings) Your family Spouse family Both families (Note, new marriages are often interfered with by member(s) of the family(s) from which couple come. If you marked any of the above please explain below, or be sure to discuss this with your counselor.) ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Financial concerns Marital communications Disputes over child discipline Failure to hold job Prior marriage(s) Illness Depressions Temperament Aloofness Poor time management Alcohol or drug usage or both Failure to share Prior sexual molestation Sexual unfaithfulness Demeaning Acts Abandonment Sexual Insensitivity Slovenliness Hygiene Other Please use the space below to either explain any blocks marked above or to give other reason for problems in this previous marriage: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Has this questionnaire reminded you of something going on in your present marriage? If so explain below. ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ use back of this page if necessary. ___ I was abused as a child by a family member or a friend of the family. (If checked underline which or both) On the reverse side use the indicated portion to describe any checked responses in this section. If you need additional paper your counselor will provide it. Verbal Abuse Verbal abuse is the most common form of abuse and it is present when almost every other type of abuse takes place. Verbal abuse involves the least controllable member of the body, the tongue. Check the following statements that are true ___ My spouse verbally abuses me. (In cases of separation or divorce answer true as if present tense applies.) ___ My spouse verbally abuses me by raising their voice, shouting, or screaming. ___ My spouse uses cursing when he/she verbally abuses me. ___ My spouse uses demeaning language when he/she verbally abuses me. (Examples of demeaning language would be words that say a person is no good, fat, ugly, stupid, etc.) ___ My spouse uses verbal abuse if my actions do not please him/her. ___ My spouse uses threatening body language. (Threatening body language includes aggressive inclining the body toward the other person, use of hands in wild gesture, etc., attempting to maneuver so as to tower over the other person.) ___ My spouse verbally abuses me by bringing up my past. ___ My spouse verbally abuses me by criticizing my family. ___ My spouse verbally abuses me in front of children, friends, or family. I need to tell the counselor the following about my experience of verbal abuse: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Previous Marriages My first marriage was to ________________________________ we were married ___ years and ___ months. This marriage ___ was, ___ was not abusive. If it was abusive, but not in the same way as your current marriage, indicate how it is different. ____________________________________________________________________________________ ____________________________________________________________________________________ My second marriage was to _____________________________ we were married ___ years and ___ months. This marriage ___ was, ___ was not abusive. If it was abusive, but not in the same way as your current marriage, indicate how it is different. ____________________________________________________________________________________ ____________________________________________________________________________________ My third marriage was to ______________________________ we were married ___ years and ___ months. This marriage ___ was ___ was not abusive. If it was abusive, but not in the same was as you current marriage, indicate how it is different. ____________________________________________________________________________________ ____________________________________________________________________________________ (If you have had more than three previous marriages, talk this over with your counselor.) Other Abusive Relationships How many cohabitation relationships have you been in that were abusive? ____ What was the longest period you were in an abusive relationship of this type? ___ yrs. and ___ mos. What was the shortest time you were in an abusive relationship of this type? ___ yrs. and ___ mos. If the abusive relationship(s) were unlike that in you current marriage, describe how they were different below: ____________________________________________________________________________________ ____________________________________________________________________________________ How many dating relationships have you been in that were abusive? ___ What was the longest period of time you dated someone who abused you? ___ yrs. ___ mos. ___ times. If the dating abuse(s) were unlike that in your current marriage, describe how they were different below: ____________________________________________________________________________________ ____________________________________________________________________________________ If your parent(s) or family member was abusive tell who and how. _______________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ If your parents friend(s) or your friend(s) were abusive tell who, which relationship, and how. __________ ____________________________________________________________________________________ ____________________________________________________________________________________ Emotional Abuse Though verbal abuse is often emotional abuse as well; it also can incorporate with or be exclusively limited to mental abuse. Emotional abuse also takes place when physical and sexual abuse occurs. The inquiry here is limited to specific areas of emotional abuse where forms other than mental may or may not be present. Emotional abuse has to do with what you are feeling within yourself as a response to the activities of another person, which in this case is your spouse. ___ My spouse emotionally abuses me. ___ I have fears of being abandoned as a result of what my spouse is communicating to me. ___ I often feel dumb, ugly, clumsy, or somehow less worthwhile after being with my spouse. (Circle all that apply) ___ Sometimes sleep evades me because of something that has taken place in relationship with my Spouse. ___ My children either do not, or I feel they do not, respect me because of what my spouse conveys in his/her attitude towards me. ___ I do not think as highly of myself as I once did before I married. ___ Some things I once did, I am no longer confident to perform because of my spouses opinion. ___ I have nightmares in which my spouse is a central negative figure. ___ I fear, though they have done nothing, my spouse might like to kill me or do me harm I need to tell the counselor the following about my experience of emotional or mental abuse. ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Physical Abuse Physical abuse might incorporate other forms of abuse into its makeup. But for our purposes inquiry is confined to actions that involve active contact, the threat and use of violence, and the withholding of the necessities for life and health. ___ My spouse physically abuses me. By denial of needs ___. Pushing & Shoving ___ Violence ___. If physical needs have been denied, whether it be food, clothing, medical care, prescriptions, etc. Describe that abuse below. ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Physical abuse performed by physical contact including violence is not in Gods plan for marriage partners any more than other forms of abuse. Sometimes people misidentify physical abuse that involves grabbing sexual organs, i.e. breasts and genitalia as sexual abuse when it is only aimed at inflicting pain and not intended to be sexual. Pinching, punching, scratching are abusive when they are more than occasional; inflict real pain; done with malice; prolonged; against the recipients will. Abuse is abuse whenever the recipient feels abused. Describe the physical contact or violence abuse you experience below. ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ SEXUAL ABUSE- Sexual abuse, like physical abuse can include not only what is done to a person, but in a marriage include what is denied the spouse in the marriage relationship. Sexual abuse is both passive and active, and does not necessarily involve physical contact. If you have a history of being sexually abused it should have already shown up in the first part of your responses to questions about abuse from others. If you omitted to respond to that inquiry during the first part of your survey preparation, please go back and do so, If you need more room write on the back of this and the preceding page. Many people find it difficult to respond to inquiries concerning sexual abuse. Sometimes they are not sure what they have experienced is sexual abuse. The design of this part of the inquiry is longer and more detailed than the preceding portions because of the survey. By the time you have checked the parts applicable to you, communication about the problem with your counselor should actually be a little easier. ___ I have been sexually abused by being denied the normal coital relationship within marriage by my spouse. ___ I have been sexually abused by being forcibly took sexually by my spouse. ___ I have been sexually abused by being forced to have sexual relationship with my spouse at improper or inconvenient times and/or places. ___ I have been sexually abused by my partner inflicting pain upon me in sexual activity. ___ I have been sexually abused by being forced to perform sexual acts that made be feel demeaned. ___ I have been sexually abused by having my sexual performance harshly mocked by my spouse. ___ I have been publicly ridiculed as a sexual partner. ___ I have been sexually abused by being forced to watch pornographic films, etceteras, by my spouse. ___ I have been sexually abused by being put on physical display before others by my spouse. ___ I have been sexually abused by being forced to have sexual contact in front of the children. ___ I have been sexually abused by being forced to be present when others were engaging in sexual activity. ___ I have been sexually abused by being forced to have sexual relationships with other people by my spouse. ___ I have been sexually abused by being coerced into participation in group sexual activity. ___ I have been sexually abused through being forced into sadistic sexual roles by my spouse. ___ I have been sexually abused through being forced into masochistic sexual roles by my spouse. ___ I have been sexually abused through being forced into bondage sexual roles by my spouse. ___ I have been sexually abused by being forced into lesbian/homosexual encounters by my spouse. ___ I have been sexually abused by being forced into participation in bestiality by my spouse. ___ I have been sexually abused by my spouse in ways not covered in this survey What I would like to tell my counselor about my experience of sexual abuse is _____________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________
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Jonsquill Ministries
P. O. Box 752
Buchanan, Georgia 30113
171001-1