ࡱ> ` fnbjbjss 1nt>ppp8"qs*{H^^^z%Lq($h58%"8^^+]^^^{ n@p֬<s0,>ה,$'88RXjpdp Saint Louis Consultation Center 2039 North Geyer Road St. Louis, Missouri 63131 Phone: (314) 909-4620 Fax: (314) 909-4622 http://stlconsult.org information@stlconsult.org Psychosocial Questionnaire This questionnaire is designed to help you provide information about your history and present life situation. Its purpose is to assist in the comprehensive assessment for which you have been scheduled. It will remain as part of your confidential file at the Consultation Center. This form will only be seen by those professionals with whom you have contact during the course of the assessment. We encourage you to be as thorough as possible as you complete this form. Please answer the questions in the space provided. Feel free to use both sides of each sheet or add additional sheets if necessary. We understand that this questionnaire includes sensitive information and appreciate your cooperation. SECTION I: BASIC INFORMATION  Name  FORMTEXT       Address in St. Louis area:  FORMTEXT        FORMTEXT       Permanent Address (if different):  FORMTEXT       Telephone in St. Louis area:  FORMTEXT       Permanent Telephone:Work:  FORMTEXT       Home:  FORMTEXT       Cell:  FORMTEXT       Place of Work:  FORMTEXT        FORMTEXT       Occupation/Ministry:  FORMTEXT       Race/Ethnic Background  FORMTEXT       Age:  FORMTEXT       Date of Birth  FORMTEXT       Height:  FORMTEXT       Weight:  FORMTEXT       Social Security Number:  FORMTEXT       Major Superior or Ordinary:  FORMTEXT       Contact Person (if different):  FORMTEXT       Diocese/Community:  FORMTEXT       Address:  FORMTEXT       Telephone:  FORMTEXT       How did you or your referring  FORMTEXT       superior learn of the St. Louis Consultation Center? SECTION II: THE PROBLEM 1. Describe in your own words why you are seeking or have been referred for evaluation. FORMTEXT       2. When did this problem begin? FORMTEXT        3. What led to the referral for this evaluation?  FORMTEXT        4. Have you been in psychiatric and/or psychological treatment for this problem or for any other problem in the past? Please provide details of any previous treatment.  FORMTEXT        FORMTEXT       5. What would you like to achieve as a result of the evaluation process? FORMTEXT        SECTION III: HEALTH HISTORY 1. List all medication which you currently take on a regular basis.  FORMTEXT       2. List all surgeries which you have had, including dates and reasons for the operation. Were there any complications?  FORMTEXT       3. List any history of serious illness or any ongoing chronic illnesses or conditions for which you are currently being treated.  FORMTEXT       4. List commonly recurring or chronic symptoms from which you currently suffer.  FORMTEXT       5. Please provide the names of your current physician(s) and/or psychiatrist, including telephone numbers.  FORMTEXT       6. When was your last physical examination? What were the results as you understood them?  FORMTEXT        SECTION IV: FAMILY HISTORY 1.. Were you raised by your biological parents? If not, by whom? Were there others who helped raise you? FORMTEXT       2. Did any members of your extended family live with you during your childhood or adolescence? FORMTEXT       3. Did you family relocate? If so, what was this experience like for you? FORMTEXT       4. Are your parents still living? If not, when and how did they die? FORMTEXT       5, Is there any family history of mental illness? That is, did any family member suffer from depression, anxiety, schizophrenia, bipolar (manic-depressive) disorder, or other emotional or psychiatric difficulties? FORMTEXT       6. Is there any history of physical, emotional, or sexual abuse in your family? FORMTEXT       7. Have you ever been a victim of such abuse outside your family? FORMTEXT       8. If one or both of your parents worked outside the home, please describe their occupations. FORMTEXT       9. What was the nature of discipline in your home? FORMTEXT       10. Did either of your parents abuse alcohol or any other drug? FORMTEXT       11. How many brothers and sisters did you have and what was your place in the birth order? FORMTEXT       12. Do your siblings have any major life problems (drug addiction, alcoholism, mental illness)? FORMTEXT       13. Briefly describe your experience of life in childhood. FORMTEXT       14. Describe your parents' relationship with each other and their relationship with you. FORMTEXT       15. What was unique about you? How would your family describe you to differentiate you from others in the family? FORMTEXT       16. Please describe your current relationships with parents and siblings. If siblings have died, please list years and causes of death. FORMTEXT        SECTION V: SOCIAL, SEXUAL, AND DATING HISTORY 1. Describe your social relations with peers and teachers in elementary and high school.  FORMTEXT       2. Describe your dating experience, if any. When did you begin dating? How would you describe the experience?  FORMTEXT       3. When and how did you learn about sex? How comfortable was your family with this subject?  FORMTEXT       4. How comfortable are you in dealing with sexual issues?  FORMTEXT       5. What are your current sources of social support? How helpful are these to you?  FORMTEXT       6. How successful do you feel in developing and maintaining close relationships in your life?  FORMTEXT       7. Are there persons in your immediate or general community or social circle who make your life especially difficult?  FORMTEXT       8. What have been the benefits, difficulties, and/or challenges of living a celibate lifestyle?  FORMTEXT       9. How long have you known your closest friend?  FORMTEXT       10.Have you shared the concerns which led to this assessment with anyone but your superiors? FORMTEXT       11.Have you ever been sexually harassed or abused?Yes  FORMCHECKBOX  No  FORMCHECKBOX 12.If yes, please explain how old you were, what happened, and how this affected you. FORMTEXT        SECTION VI: DESCRIPTIONS OF SELF 1. Describe yourself, including five adjectives that best describe you.  FORMTEXT       2. What is the source of your greatest happiness?  FORMTEXT       3. What is the source of your greatest unhappiness?  FORMTEXT       4. What do you see as your principal strengths?  FORMTEXT       5. What do you see as your principal shortcomings?  FORMTEXT       6. What would you describe as your most significant accomplishments in life thus far?  FORMTEXT       7. What would you identify as your most frustrating experience in life so far?  FORMTEXT       8. Have you recently experienced any losses or sources of grief?  FORMTEXT       9. Is there anything about yourself or your history that would be helpful for us to know, matters which would not be obvious to a casual acquaintance or even to a moderately good friend?  FORMTEXT       10. How do you spend time outside of work?  FORMTEXT       11. How would you like to be spending free time?  FORMTEXT        SECTION VII: SELF-CARE 1. Do you engage in any regular form of exercise? Yes  FORMCHECKBOX  No  FORMCHECKBOX 2. Describe your patterns of sleep. FORMTEXT       3. Describe your eating habits.  FORMTEXT       4. Have you even been in legal trouble?Yes  FORMCHECKBOX  No  FORMCHECKBOX 5. Do you have a support network of people with whom you can share you struggles & concerns on an ongoing basis?Yes  FORMCHECKBOX  No  FORMCHECKBOX 6. Do you have close friends among the presbyterate of your diocese or among members of your religious congregation?Yes  FORMCHECKBOX  No  FORMCHECKBOX 7. Do you think you have the skills to deal with inter-personal conflicts when they arise?Yes  FORMCHECKBOX  No  FORMCHECKBOX 8. How do you deal with feelings of anger? FORMTEXT       9. Are you a part of any twelve-step fellowship? (AA, GA, SA, NA, etc.)Yes  FORMCHECKBOX  No  FORMCHECKBOX 10. If yes, do you have a sponsor with whom you are in regular contact?Yes  FORMCHECKBOX  No  FORMCHECKBOX  SECTION VIII: SYMPTOM CHECKLIST The following are common symptoms that people have when they suffer from various forms of affective disorders, such as depression or anxiety. Some of the symptoms are repetitious because they are grouped under different possible clusters. Depressive Disorders 1. How would you describe your mood lately?Stable  FORMCHECKBOX  Variable  FORMCHECKBOX  Mostly depressed  FORMCHECKBOX  Mostly anxious  FORMCHECKBOX  Always depressed or anxious  FORMCHECKBOX 2. How would you rate your energy level?Good  FORMCHECKBOX  Less than usual  FORMCHECKBOX  Fatigued  FORMCHECKBOX 3 Do you continue to experience pleasure in your life and interest in your normal activities?Yes  FORMCHECKBOX  No  FORMCHECKBOX 4. Has your weight changed significantly (10 pounds or more) within the past year?Yes  FORMCHECKBOX  No  FORMCHECKBOX 5. Within the past month?Yes  FORMCHECKBOX  No  FORMCHECKBOX 6. Is your sleep disturbed?Yes  FORMCHECKBOX  No  FORMCHECKBOX 7. If yes, please explain how FORMTEXT       8. Are you sleeping more than usual (more than eight or nine hours each day?)Yes  FORMCHECKBOX  No  FORMCHECKBOX 9. Have you ever had periods where you did not require much sleep?Yes  FORMCHECKBOX  No  FORMCHECKBOX 10. If yes, how long did you go without sleeping?  FORMTEXT      11. Do you have a difficult time settling down or relaxing?Yes  FORMCHECKBOX  No  FORMCHECKBOX 12. Do you experience feelings of worthlessness or guilt?Yes  FORMCHECKBOX  No  FORMCHECKBOX 13. You do have difficulty concentrating/reading?Yes  FORMCHECKBOX  No  FORMCHECKBOX 14. Do you find yourself sad or easily moved to tears?Yes  FORMCHECKBOX  No  FORMCHECKBOX 15. Do you find yourself angry or irritable?Yes  FORMCHECKBOX  No  FORMCHECKBOX 16. Have you had recurrent thoughts of death or dying?Yes  FORMCHECKBOX  No  FORMCHECKBOX 17. Have you had suicidal thoughts?Yes  FORMCHECKBOX  No  FORMCHECKBOX 18. If yes, have you thought of how you might do it? Yes  FORMCHECKBOX  No  FORMCHECKBOX 19. Have you ever had thoughts of harming yourself or of causing yourself physical pain? Yes  FORMCHECKBOX  No  FORMCHECKBOX 20. If yes, have you ever engaged in self-injurious acts (cutting, burning, etc)?Yes  FORMCHECKBOX  No  FORMCHECKBOX 21. If yes, please specify the behavior: FORMTEXT       22. If yes, did you receive medical attention for injuries?Yes  FORMCHECKBOX  No  FORMCHECKBOX 23. If yes, when did you last engage in such behavior?  FORMTEXT      24. If you believe you are depressed, how long have you felt this way? A few days  FORMCHECKBOX  Two weeks  FORMCHECKBOX  Six months  FORMCHECKBOX  More than six months FORMCHECKBOX  25.Is there anything else about your mood that concerns you (e.g., racing thoughts? mood swings? feeling out of control?) FORMTEXT        Panic Have you had any of the following symptoms within the past six months? Palpitations, pounding heart, or accelerated heart rate?Yes  FORMCHECKBOX  No  FORMCHECKBOX  sweating without sustained physical activity Yes  FORMCHECKBOX  No  FORMCHECKBOX  Trembling/shakingYes  FORMCHECKBOX  No  FORMCHECKBOX  Sensations of shortness of breath or smotheringYes  FORMCHECKBOX  No  FORMCHECKBOX  Feeling of chokingYes  FORMCHECKBOX  No  FORMCHECKBOX  Chest pain or discomfortYes  FORMCHECKBOX  No  FORMCHECKBOX  Nausea or abdominal distressYes  FORMCHECKBOX  No  FORMCHECKBOX  feeling dizzy, unsteady, lightheaded, or faint Yes  FORMCHECKBOX  No  FORMCHECKBOX  derealization (feelings of unreality or feeling detached from self)Yes  FORMCHECKBOX  No  FORMCHECKBOX  fear of losing control or going crazyYes  FORMCHECKBOX  No  FORMCHECKBOX  Fear of dyingYes  FORMCHECKBOX  No  FORMCHECKBOX  numbness or tingling sensations, especially in your hands or feetYes  FORMCHECKBOX  No  FORMCHECKBOX  chills or hot flashesYes  FORMCHECKBOX  No  FORMCHECKBOX If yes to any of these symptoms, did you seek medical consultation?Yes  FORMCHECKBOX  No  FORMCHECKBOX  If yes, what were the results as you understood them? FORMTEXT        OCD Have you had recurrent or persistent thoughts, impulses or images that seem inappropriate to you and that cause you anxiety?Yes  FORMCHECKBOX  No  FORMCHECKBOX If yes, do you try to suppress these in any way?Yes  FORMCHECKBOX  No  FORMCHECKBOX Do you engage in any repetitive behavior, such as hand washing or checking, that you feel driven to perform? If yes, please specify the behavior:Yes  FORMCHECKBOX  No  FORMCHECKBOX   FORMTEXT      Do you engage in mental acts, such as counting or repeating words silently, that you feel driven to perform? If yes, please specify the behaviorYes  FORMCHECKBOX  No  FORMCHECKBOX   FORMTEXT      If you have such behaviors, do you recognize them as irrational?Yes  FORMCHECKBOX  No  FORMCHECKBOX  PTSD Have you been exposed to an event in which you have felt seriously threatened and to which your response was to feel intense fear, helplessness, or horror? Yes  FORMCHECKBOX  No  FORMCHECKBOX If yes, please specify what and when it happened  FORMTEXT      Do you have disturbing memories of such an event?Yes  FORMCHECKBOX  No  FORMCHECKBOX Do you have distressing dreams or nightmares about frightening things?Yes  FORMCHECKBOX  No  FORMCHECKBOX Do you sometimes feel that past traumatic events were recurring in the present?Yes  FORMCHECKBOX  No  FORMCHECKBOX Do you sometimes get lost in a daydream thinking about some disturbing event?Yes  FORMCHECKBOX  No  FORMCHECKBOX Do you avoid talking about certain aspects of your life that you find distasteful? (These might include your family life, unhappy experiences, traumatic experiences you have had.)Yes  FORMCHECKBOX  No  FORMCHECKBOX Do you sometimes feel detached or estranged from others for no apparent reason?Yes  FORMCHECKBOX  No  FORMCHECKBOX Do you have a difficult time experiencing your feelings?Yes  FORMCHECKBOX  No  FORMCHECKBOX Do you have a sense that life is short?Yes  FORMCHECKBOX  No  FORMCHECKBOX Do you have difficulty falling or staying asleep?Yes  FORMCHECKBOX  No  FORMCHECKBOX Are you irritable or given to outbursts of anger?Yes  FORMCHECKBOX  No  FORMCHECKBOX Do you have trouble concentrating?Yes  FORMCHECKBOX  No  FORMCHECKBOX Are you watchful of others and/or mistrustful?Yes  FORMCHECKBOX  No  FORMCHECKBOX Do you startle easily?Yes  FORMCHECKBOX  No  FORMCHECKBOX Are there any other thoughts, memories, or dreams you have that concern you? If so, please describe:Yes  FORMCHECKBOX  No  FORMCHECKBOX   FORMTEXT       GAD 1. Do you worry excessively?Yes  FORMCHECKBOX  No  FORMCHECKBOX 2. Do you find worry difficult to control?Yes  FORMCHECKBOX  No  FORMCHECKBOX 3. Have you had any of the following symptoms?Yes  FORMCHECKBOX  No  FORMCHECKBOX  restlessness or feeling keyed up or on edgeYes  FORMCHECKBOX  No  FORMCHECKBOX  being easily fatigued Yes  FORMCHECKBOX  No  FORMCHECKBOX  difficulty concentrating or mind going blank Yes  FORMCHECKBOX  No  FORMCHECKBOX  irritabilityYes  FORMCHECKBOX  No  FORMCHECKBOX  muscle tension Yes  FORMCHECKBOX  No  FORMCHECKBOX  sleep disturbance (difficulty falling asleep or staying asleep or restless unsatisfying sleep)Yes  FORMCHECKBOX  No  FORMCHECKBOX  SECTION IX: COMPULSIONS/ADDICTIONS Please check all that apply: Alcohol/Drug Use 1. Do you drink alcoholic beverages?Yes  FORMCHECKBOX  No  FORMCHECKBOX 2. If yes, how much and how often do you drink alcohol? FORMTEXT      3. Did anyone in your family of origin abuse alcohol or drink problematically?Yes  FORMCHECKBOX  No  FORMCHECKBOX 4. Have you ever felt that you should cut down on your drinking?Yes  FORMCHECKBOX  No  FORMCHECKBOX 5. Have people ever angered or annoyed you by criticizing your drinking?Yes  FORMCHECKBOX  No  FORMCHECKBOX 6. Have you ever felt bad or guilty about your drinking?Yes  FORMCHECKBOX  No  FORMCHECKBOX 7. Have you ever taken a drink to calm your nerves in the morning?Yes  FORMCHECKBOX  No  FORMCHECKBOX 8. Have you ever not remembered something that occurred when you were drinking?Yes  FORMCHECKBOX  No  FORMCHECKBOX 9. Have you ever gotten drunk when you did not intend to do so?Yes  FORMCHECKBOX  No  FORMCHECKBOX 10. Do you drink alcohol on a daily basis?Yes  FORMCHECKBOX  No  FORMCHECKBOX 11. Does your use of alcohol prevent you from pursuing other forms of recreation, relaxation or other relationships?Yes  FORMCHECKBOX  No  FORMCHECKBOX 12. Have you ever used any illegal substance for the purpose of altering your consciousness?Yes  FORMCHECKBOX  No  FORMCHECKBOX 13. Have you ever used prescription medicine in a manner inconsistent with the prescription of your physician?Yes  FORMCHECKBOX  No  FORMCHECKBOX 14. Have you every collected more than one prescription from different physicians so as to procure a supply?Yes  FORMCHECKBOX  No  FORMCHECKBOX  Sexual Addiction/Compulsivity 1. 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Do you regularly purchase sexually explicit magazines or videos?Yes  FORMCHECKBOX  No  FORMCHECKBOX 3. Do you now or have you viewed sexually explicit material on the Internet?Yes  FORMCHECKBOX  No  FORMCHECKBOX 4. Have you done this on more than an occasional basis? Yes  FORMCHECKBOX  No  FORMCHECKBOX 5. Have you ever been involved in sexually active relationships that were inconsistent with your celi-bate promise or vow of chastity?Yes  FORMCHECKBOX  No  FORMCHECKBOX 6. Has anyone ever complained about your sexual behavior?Yes  FORMCHECKBOX  No  FORMCHECKBOX 7. Do you have trouble stopping or restraining your sexual behavior?Yes  FORMCHECKBOX  No  FORMCHECKBOX 8. Have you felt remorse about your sexual behavior?Yes  FORMCHECKBOX  No  FORMCHECKBOX 9. Has your sexual behavior ever created problems for you, your family, or members of your community?Yes  FORMCHECKBOX  No  FORMCHECKBOX 10. Have you ever sought help for sexual difficulties??Yes  FORMCHECKBOX  No  FORMCHECKBOX 11. Have you ever worried that others would find out about your sexual behavior?Yes  FORMCHECKBOX  No  FORMCHECKBOX 12. Has anyone been hurt by your sexual behavior?Yes  FORMCHECKBOX  No  FORMCHECKBOX 13. Have you ever participated in sexual activity in exchange for money or gifts?Yes  FORMCHECKBOX  No  FORMCHECKBOX 14. Have you had periods of sexual abstinence interspersed with periods of sexual activity?Yes  FORMCHECKBOX  No  FORMCHECKBOX 15. Have you tried to stop sexual activity and failed?Yes  FORMCHECKBOX  No  FORMCHECKBOX 16. Do you hide your sexual behavior from others?Yes  FORMCHECKBOX  No  FORMCHECKBOX 17. Have you had multiple sexual partners during the same time period?Yes  FORMCHECKBOX  No  FORMCHECKBOX 18. Have you ever felt degraded by your sexual behavior?Yes  FORMCHECKBOX  No  FORMCHECKBOX 19. Have sexual or romantic fanta-sies been a way for you to escape stress or conflict in your life?Yes  FORMCHECKBOX  No  FORMCHECKBOX 20. Have you ever felt depressed after a sexual incident?Yes  FORMCHECKBOX  No  FORMCHECKBOX 21. Have you ever engaged in sadomasochistic behavior?Yes  FORMCHECKBOX  No  FORMCHECKBOX 22. Has your sexual activity interfered with your life or ministry?Yes  FORMCHECKBOX  No  FORMCHECKBOX 23. Have you been sexual with minors?Yes  FORMCHECKBOX  No  FORMCHECKBOX 24. Do you feel controlled by your sexual desire or fantasies of romance?Yes  FORMCHECKBOX  No  FORMCHECKBOX 25. Do you every think your sexual desire is stronger than you are?Yes  FORMCHECKBOX  No  FORMCHECKBOX 26. Has masturbation been problematic in your life?Yes  FORMCHECKBOX  No  FORMCHECKBOX  27. Have you ever met a person online and arranged to meet for the purpose of sexual activity?Yes  FORMCHECKBOX  No  FORMCHECKBOX 28. Have you ever gone to a bar to pick up person for the purpose of sexual activity?Yes  FORMCHECKBOX  No  FORMCHECKBOX 29. Have you ever 'cruised' a park, rest stop, or other venue for the purpose of sexual activity?Yes  FORMCHECKBOX  No  FORMCHECKBOX 30 Have you every had physical/ sexual contact with a person whom you were counseling or with a member of your parish?Yes  FORMCHECKBOX  No  FORMCHECKBOX  Eating 1. Do you eat when you are not hungry?Yes  FORMCHECKBOX  No  FORMCHECKBOX 2. Do you go on 'eating binges' for no apparent reason?Yes  FORMCHECKBOX  No  FORMCHECKBOX 3. Do you spend a significant amount of time thinking about food?Yes  FORMCHECKBOX  No  FORMCHECKBOX 4. Do you have feelings of guilt and/or remorse after overeating?Yes  FORMCHECKBOX  No  FORMCHECKBOX 5. Do you prefer to eat alone?Yes  FORMCHECKBOX  No  FORMCHECKBOX 6. Do you eat secretly?Yes  FORMCHECKBOX  No  FORMCHECKBOX 7. Do you make a point of eating sensibly in the presence of others, only to overeat when you are alone? Yes  FORMCHECKBOX  No  FORMCHECKBOX 8. Do you hoard or hide food? Yes  FORMCHECKBOX  No  FORMCHECKBOX  9. Have you tried to diet for a few days and then abandoned it as hopeless? Yes  FORMCHECKBOX  No  FORMCHECKBOX 10. Do you resent others' commenting on your weight or eating?Yes  FORMCHECKBOX  No  FORMCHECKBOX 11. Do you eat to provide a sense of emotional comfort to yourself?Yes  FORMCHECKBOX  No  FORMCHECKBOX 12. Does your eating or your weight make you unhappy?Yes  FORMCHECKBOX  No  FORMCHECKBOX 13. Do you suffer from medical ailments that are attributable to or exacerbated by excess weight or overeating?Yes  FORMCHECKBOX  No  FORMCHECKBOX  Gambling 1. Have you ever lost time from work or school due to gambling?Yes  FORMCHECKBOX  No  FORMCHECKBOX 2. Has gambling ever made your home or community life unhappy? Yes  FORMCHECKBOX  No  FORMCHECKBOX 3. Does gambling affect your reputation? Yes  FORMCHECKBOX  No  FORMCHECKBOX 4. Have you ever felt remorse after gambling? Yes  FORMCHECKBOX  No  FORMCHECKBOX 5. Have you ever gambled to get money with which to pay debts or otherwise solve financial difficulties?Yes  FORMCHECKBOX  No  FORMCHECKBOX 6. Has gambling caused a decrease in your ambition or efficiency? Yes  FORMCHECKBOX  No  FORMCHECKBOX 7. After losing money, have you ever felt you must return to gambling as soon as possible and win back your losses? Yes  FORMCHECKBOX  No  FORMCHECKBOX 8. After a win have you ever had a strong urge to return and win more? Yes  FORMCHECKBOX  No  FORMCHECKBOX 9. Have you often gambled until your last dollar was gone? Yes  FORMCHECKBOX  No  FORMCHECKBOX 10. Have you ever borrowed to finance your gambling? Yes  FORMCHECKBOX  No  FORMCHECKBOX 11. Have you ever sold anything to finance gambling? Yes  FORMCHECKBOX  No  FORMCHECKBOX 12. Have you ever been reluctant to use 'gambling money' for normal expenditures? Yes  FORMCHECKBOX  No  FORMCHECKBOX 13. Has gambling made you careless of your welfare? Yes  FORMCHECKBOX  No  FORMCHECKBOX 14. Have you every gambled longer than you planned?Yes  FORMCHECKBOX  No  FORMCHECKBOX 15. Have you every gambled to escape worry or trouble?Yes  FORMCHECKBOX  No  FORMCHECKBOX 16. Have you ever committed, or considered committing, an illegal act to finance gambling?Yes  FORMCHECKBOX  No  FORMCHECKBOX 17. Has gambling caused you to have difficulty sleeping?Yes  FORMCHECKBOX  No  FORMCHECKBOX 18. Do arguments, disappointments, or frustrations create within you an urge to gamble?Yes  FORMCHECKBOX  No  FORMCHECKBOX 19. Have you ever had an urge to celebrate good fortune by a few hours of gambling?Yes  FORMCHECKBOX  No  FORMCHECKBOX 20. Have you ever considered self-destruction or suicide as a result of your gambling?Yes  FORMCHECKBOX  No  FORMCHECKBOX  Money Management/Spending 1. Are you living within the means set by your community or expected as a person in ministry?Yes  FORMCHECKBOX  No  FORMCHECKBOX 2. Are you responsible for parish/community funds? Yes  FORMCHECKBOX  No  FORMCHECKBOX 3. Have you every misspent such funds? Yes  FORMCHECKBOX  No  FORMCHECKBOX 4. Have you ever bought things you did not need? Yes  FORMCHECKBOX  No  FORMCHECKBOX 5. Have you felt that your spending habits were out of control? Yes  FORMCHECKBOX  No  FORMCHECKBOX 6. Do you have feelings of shame/embarrassment about your spending? Yes  FORMCHECKBOX  No  FORMCHECKBOX 7. Have you every shuffled funds from one account to another to mask you actual spending? Yes  FORMCHECKBOX  No  FORMCHECKBOX  Miscellaneous Do you engage in any other kinds of behavior, such as exercise, hoarding or collecting things, which might be described as addictive or compulsive or which other people have commented upon?Yes  FORMCHECKBOX  No  FORMCHECKBOX   FORMTEXT       SECTION X: EDUCATION 1. Please list any advanced degrees which you hold, the nature of your studies and the dates and institutions from which they were granted. FORMTEXT       2. Please describe other training or CPE experience. FORMTEXT        SECTION XI: OCCUPATIONAL HISTORY 1. List in chronological order your work/ministry history. Include dates and reasons for changing.  FORMTEXT       2. What is your current position? How long have you held it? How satisfied are you with it? What are the most satisfying aspects of it and the most frustrating?  FORMTEXT       3. How do you get along with your colleagues at work?  FORMTEXT       4. How do you get along with your supervisors/superiors?? FORMTEXT       5. How do you get along with those you supervise or employ? FORMTEXT       6. What would you like to be doing occupationally in ten years? FORMTEXT        SECTION XII: OTHER MINISTRY 1. Describe your involvement in the local civic community. Do you belong to any social clubs or organizations?  FORMTEXT       2. Describe involvement in any diocesan, state or national church organization. FORMTEXT       3. What causes or movements within the Church or independent of it are most dear to you?  FORMTEXT       4. Have you ministered abroad? Yes  FORMCHECKBOX  No  FORMCHECKBOX 5. If you have ministered abroad, have you undergone a re-entry program to prepare you for re-entering American culture?  FORMTEXT        SECTION XIII: FORMATION 1. What kind of elementary did you attend (parochial, public, private)?  FORMTEXT       2. What kind of high school did you attend? FORMTEXT       3. If you attended a minor seminary, how was that experience for you? FORMTEXT       4. If you attended seminary, when and where was that and what was the experience like for you?  FORMTEXT       5. If you participated in a novitiate program, please describe what it was like for you.  FORMTEXT       6. Were your studies shortened or accelerated for any reason? Please explain.  FORMTEXT       7. If you studied theology, where and when did you do so? Was there any interruption of your studies? FORMTEXT       8. If you are ordained: when, where and by whom were you ordained? FORMTEXT       9. If you are professed, when was it? FORMTEXT       10. Describe your experience of the formation process. 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