Youth Counseling Questionnaire

Participant Information

Full Name(Required)

Participant Age(Required)

Email(Required)

Phone(Required)

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

Questions

Please describe your sexual history beginning with your first exposure, and include methods (porn, masturbation, sexual encounters, etc), devices used (smartphones, computers, etc), the last time you acted out, and frequency:

How much of your sexual history is your parents aware of?

Do you have a girlfriend? If so, are you sexually active?

Please describe your relationships with your parents, including biological family and step-parents, where applicable.

Please describe your efforts to date in searching for recovery (groups, counseling, etc):

Are you attending a youth group at church?

Have you had any exposure to or been involved with occult activities?

Have you ever been molested or abused?

Are you on any medications? If so please list the names and diagnosis.

Are you having any suicidal thoughts?

What is your relationship with the Lord like?

What would you say is your greatest need and/or how we could help you the most?

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