Matt Oxley (revoxley501) wrote in deliverancemini,
Matt Oxley
revoxley501
deliverancemini

rough draft, please comment on additions or subtractions

Survey for applicants to the Ministry program of Rev. Matt Oxley

All information herein is optional, but aids in the ministry process. Information will be held in the strictest of confidentiality with absolutely no exceptions. Please be as detailed as you are comfortable with. If you are not comfortable giving a name please use a screen name or surname/pen name for reference. If you are not comfortable giving a location or any other identifiers please briefly tell why, giving a general region would still be very much appreciated.

Contact Info:


Name:__________________________________ Date:___/___/____

Surname/SN:______________________ MSN: ____________________ Y!: ____________________

Email:_____________________________________ AIM: _____________________ Gtalk: __________________

Location: ___________________________ Other: ____________________

Home phone: ___________________________

Marital Status(circle one): Single Married Engaged Divorced

Number of Children: _______________



Medical Info:

Have you ever been diagnosed as or with: __Schizophrenic __Bi-polar __Clinically Depressed __Manically depressed __Neurotic __Narcissistic __Split personality __Dissociative Identity Disorder __Multiple Personality Disorder __Stockholm Syndrome __Anti Social __Post Traumatic Stress Disorder __Other:_____________

Please attach copies of any documentation verifying these claims (with any information you want kept private marked or blurred out).

Are you on any medication? Y/N What medication, if any, are you currently using? _________________________________ _____________________________________________________________________________________________________.

Physical Ailments or Diseases: __Diabetes __Blindness __Deaf __Arthritis __Paralysis __Other:________________________ _________________________________________________________________________________________________________.

If you have ever had an IQ test, please tell the ____Age of administration and ______Score. Was this test administered by a professional? Y/N If not, where was this test administered? _____________________.


Spiritual information:

Please state your religion as of right now: ___________________________ For how long: __________________

What sect/denomination do you belong to if any: _______________________________

On a scale of 1-10, please tell how well you are doing spiritually, ten being perfect: ____

Are you a member of any other Religious or Social Clubs (Pilot, Freemasons, ETC)? If so what are they ____________________ ________________________________________________________________________________________________________

Please tell if you hold offices in any of these groups: ______________________________________________________________ _________________________________________________________________________________________________________

Do you regularly attend services or meetings with your church/coven/mosque etc? Y/N

Have you ever been involved in the Occult? Y/N


Religious History:

Please provide a history of any religious groups, covens, etc that you have been a part of, going back as far as you can remember in the following format. Please be as detailed as possible, attach another sheet if needed. Small groups or covens are just as important as larger groups. Dates need not be specific.


Religious History Cont:


___/____/___ -___/___/________________________________________/________________________________________________
Date Begin Date End Organization Position or Advancement

More information: ____________________________________________________________________________________________ ___________________________________________________________________________________________________________




___/____/___ -___/___/________________________________________/________________________________________________
Date Begin Date End Organization Position or Advancement

More information: ____________________________________________________________________________________________ ___________________________________________________________________________________________________________




___/____/___ -___/___/________________________________________/________________________________________________
Date Begin Date End Organization Position or Advancement

More information: ____________________________________________________________________________________________ ___________________________________________________________________________________________________________




___/____/___ -___/___/________________________________________/________________________________________________
Date Begin Date End Organization Position or Advancement

More information: ____________________________________________________________________________________________ ___________________________________________________________________________________________________________




___/____/___ -___/___/________________________________________/________________________________________________
Date Begin Date End Organization Position or Advancement

More information: ____________________________________________________________________________________________ ___________________________________________________________________________________________________________




___/____/___ -___/___/________________________________________/________________________________________________
Date Begin Date End Organization Position or Advancement

More information: ____________________________________________________________________________________________ ___________________________________________________________________________________________________________




___/____/___ -___/___/________________________________________/________________________________________________
Date Begin Date End Organization Position or Advancement

More information: ____________________________________________________________________________________________ ___________________________________________________________________________________________________________









Cont:

___/____/___ -___/___/________________________________________/________________________________________________
Date Begin Date End Organization Position or Advancement

More information: ____________________________________________________________________________________________ ___________________________________________________________________________________________________________




___/____/___ -___/___/________________________________________/________________________________________________
Date Begin Date End Organization Position or Advancement

More information: ____________________________________________________________________________________________ ___________________________________________________________________________________________________________




___/____/___ -___/___/________________________________________/________________________________________________
Date Begin Date End Organization Position or Advancement

More information: ____________________________________________________________________________________________ ___________________________________________________________________________________________________________




___/____/___ -___/___/________________________________________/________________________________________________
Date Begin Date End Organization Position or Advancement

More information: ____________________________________________________________________________________________ ___________________________________________________________________________________________________________




___/____/___ -___/___/________________________________________/________________________________________________
Date Begin Date End Organization Position or Advancement

More information: ____________________________________________________________________________________________ ___________________________________________________________________________________________________________




___/____/___ -___/___/________________________________________/________________________________________________
Date Begin Date End Organization Position or Advancement

More information: ____________________________________________________________________________________________ ___________________________________________________________________________________________________________




___/____/___ -___/___/________________________________________/________________________________________________
Date Begin Date End Organization Position or Advancement

More information: ____________________________________________________________________________________________ ___________________________________________________________________________________________________________









Other questions:


Have you ever (check any that apply):

__Used Quija Board

__Used Tarot cards

__Used psychic/psychic hotline

__Been in a Séance

__Been Raped

__Used hard drugs

__Been abducted by Aliens



Do you ever (check all that apply):

__”lose time”

__have black outs

__Have strange/vivid dreams

__have visions or flashbacks

__Wake up with scars/bruises

__Bleed or taste blood for no reason

__Get accused of things you don’t remember doing



How would you rate your childhood (1-10)? _____________

As a child:

Were you ever raped? Y/N Molested? Y/N Ritually abused? Y/N Tortured? Y/N

Hit/abused by parents or other adult figures? Y/N Severely bullied by peers? Y/N

Attempt Suicide? Y/N
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