Emotional, Spiritual, Physical and Relational



Emotional, Spiritual, Physical and Relational

Health Questionnaire

(Confidential)

Please complete the following information, and return it to your mentors prior to the next session.

This information will only be used to help us tailor your future mentoring sessions, and it will not be shared outside this mentoring relationship as stated in the Couple Consent for Marriage mentoring form.

A) Your Emotional and Mental Health (Questions in this section may indicate a need for professional assistance and are not intended as a diagnosis, prognosis, or mental health evaluation.)

1) Do you or have you ever suffered from depression, anxiety, or any other mental health issue?

Yes No If yes, when?      

2) Is or was this condition treated medically or professionally?

Yes No Taking medication? Yes No

3) Do you have any phobias? (e.g. excessive fear of the dark, dying, loss of a parent, etc.) If yes, please explain.     

4) Have you discussed your emotional health in detail with your fiancé?

Yes No

5) Have either of you ever been physically, verbally, or sexually abused (including rape)?

Yes No If yes, have you discussed this with a professional? Yes No

With each other? Yes No

6) Have you had or been associated with an abortion? Yes No If yes, have you discussed this with a counselor? Yes No With each other? Yes No

B) Your Spiritual Condition and Health

Please complete the following statements regarding your spiritual life without the assistance of your fiancé.

1) Is Jesus the Lord of your life? Yes No Unsure Please elaborate:      

2) Do you have a personal, saving relationship with Jesus Christ? Please describe it:      

3) When do you read your Bible and for what reasons?      

4) Describe your personal commitment to attending a church (How often? For what reasons?):      

5) Describe your prayer life and devotional time (Where? When? Why?):      

6) My definition of sin is…     

7) Describe how you deal with sin:      

8) Explain any recent changes or problems you are having with your spiritual walk:      

9) What change(s) would you like to make in your spiritual life?      

10) Have you ever been involved in a cult, the occult, astrology, fortune tellers, etc.? Yes No If yes, please describe your involvement (Dates, duration, and extent):      

C) Your Physical Health and Sexual Boundaries

1) Are there any physical health issues that you have not yet fully discussed with your fiancé?     

2) Have you had a recent physical exam with a gynecologist (her) or physician (him)?      

3) Have you discussed plans for children, family planning and contraception with each other? Yes No With your doctor? Yes No N/A

4) As the process of premarital mentoring begins, it is important to consider your sexual boundaries prior to marriage. Many couples have not taken the time to discuss boundaries with each other.

The following exercise, to be completed individually, will challenge you to identify where your sexual boundaries are. Consequently, you will know when you are approaching the limit you have set for yourself and your fiancé.

Below is an example of a possible physical progression of intimacy in a relationship:

A. Holding hands

B. Arm around shoulder/waist

C. Embracing

D. Kissing

E. French kissing

F. Arousing physical contact (clothed)

G. Fondling sexual areas (clothed or unclothed)

H. Oral sex

I. Sexual intercourse

5) As an engaged couple, have you specifically discussed your physical boundaries and how to establish a foundation of purity and pursue holiness in your relationship? Yes No

6) What step(s) in the progression listed above in question #9 are off limits for you?

A B C D E F G H I Unsure None

7) Write out your physical boundaries as you and your fiancé interpret them.      

8) What specific things are you both doing to protect those boundaries?       Has that been consistently effective for you? Yes No

9) How do you feel about the decisions you made in this area? What brought you to this conclusion?      

10) Do you have an accountability partner who regularly checks in with you about maintaining these boundaries? Yes No

11) If no, would you like one of us, as your mentors, to do this for you? Yes No Unsure

D) Relational Health

1) Do you have any broken relationships with your parents or siblings? Yes No If yes, please describe:      

2) Are you still in contact with or have emotional ties with any previous boy/girlfriends? Yes No If yes, please describe involvement (dates, frequency and extent):      

3) Do any boy/girlfriends still have contact or emotional ties with you? Yes No If yes, please describe involvement (dates, frequency, and extent):      

4) Do you have any remaining legal or financial ties from previous relationships? Yes No If yes, please describe involvement (duration and extent):      

© 2010 Jeffrey Murphy & Charles Dettman All rights reserved.

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