Confidential Personal History | Dr. Lily David Institute of Health and Healing

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CONFIDENTIAL PERSONAL HISTORY (CPH)

First Name

Email

Last Name

Phone

Name of Church (if any)

Denomination

Occupation

Education Level

Spouses Name

I was referred by...

Number of Children (ages)

Have you been in counseling? If yes, give details

Check the issues that pertain to you: rate degree of stress/urgency for applicable areas, Indicate in the range of 1 – 10 ( 1 being low, and 10 being high stress/urgency )

_____________________________________________________________

Please check any that relate to your personal life experience.

Psychic abilities, clairvoyance, divination; feeling of having “special powers.”

Inward perception of a separate personality, name or voice.

Made a secret inner vow or pact ( i.e. I will never __________ again. )

Fearful, repetitive night visitations by an evil presence.

Difficulty participating in prayer; agitation, nausea, anger, rebellion, etc.

Uncontrolled thoughts/impressions; e.g., sexual perversion, cursing, violence.

Uncontrollable compulsive behaviors: sexual sin, anger, chemical indulgence.

Preoccupation with thoughts of death, despair and hopelessness.

Uncontrollable, irrational, paralyzing fear.

Unusual, non-typical emotional expressions, e.g., laughter, sadness, crying, anger.

Extreme nervousness or negative reactions at the mention of the name of Jesus.

Emotional History - Confidential Check all that apply.

I don’t remember being loved physically as a child (hugs, being held, etc.)

My parents divorced when I was a child.

There was an adulterous affair with my parent or grandparent.

I had no father growing up because of death / divorce / preoccupation.

One of my parents/friends committed suicide

I suffered abuse from a non-parental family relationship.

I was sexually abused as a child.

I had (have) a physical/mental abnormality that brought ridicule from peers.

I experienced a severe trauma (e.g., house fire, accident, tragedy).

I was verbally abused as a child.

I was given up as a child for adoption.

I have had an unhappy marriage.

I had an alcoholic parent.

I have felt abandoned by friends.

I have had one or more abortions.

I have had one or more miscarriages?

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ABOUT US

Dr. Lily David Institute of Health & Healing, Inc. is Christ-centered, Biblically-based whole health provider, practicing telemedicine. Our mission and vision embrace the passion to dramatically improve the treatment outcomes of diseases by providing healing of the whole person—spirit, soul, and body—much more than simply managing health care outcomes or theorizing on the quality of care. We pray with our patients, His purpose is changing us, and we do all to reflect the virtue of his Glory.

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