Blessing Interview Form (Page 3 of 4) in pdf

Blessing I nterview F orm

Blessing & F amily M inistry, F FWPU-‐USA

_ _______________

Applicant N ame

( last, f irst) _ _______________________________________

D ate

5. C ompulsive B ehaviors o r A ddictions

Did y ou e ver o r a re y ou n ow e ngaged i n p ornography, c yber p orn, a lcohol, d rugs, t obacco, g ambling, v iolence

and, o r c ompulsive v ideo g ame u se? -‐ -‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐ -‐ -‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐ N o Y es

If “ yes” e xplain e ach f ully, i ncluding h ow o ften, d uring w hat t ime f rame a nd w hen w as t he l ast t ime.

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D ate o f l ast t ime _ ________________________

Is t his a h abit? I f s o, w hat a re y ou d oing t o o vercome i t? _ __________________________________________

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Receiving t he B lessing d oes n ot m ake c ompulsive b ehaviors d isappear.

These h abits s hould b e a ddressed b efore g oing t o t he B lessing.

6. H ealth C oncerns

Do y ou h ave a ny p sychological c hallenges, s uch a s d epression o r s uicidal t houghts, w hich y our p otential m atch

needs t o k now a bout? H ave y ou e ver h ad c ounseling o r u sed m edication f or a n e xtended p eriod o f t ime? D o

you h ave a ny p hysical o r h ealth c hallenges, s uch a s i nfertility, b lindness, d eafness, s tructural m alformation,

diabetes, a sthma, e tcetera, w hich y our p otential m atch n eeds t o k now a bout? D oes a ny f amily m ember h ave

a h istory o f a m ental o r p hysical h ereditary c ondition? -‐ -‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐ N o Y es

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Ver: J anuary 1 8, 2 014; K eep o riginal w ith i nterviewer o r l ocal B FM. U pload s ignature p age o nly w ith o nline a pplication.

Destroy o riginal a fter a pplicant i s B lessed.