Christ-0-Centric
REPETITIVE EVENT POTENTIAL EVALUATION ASSISTANCE TEST
(REPEAT)
Introduction: This is a marriage assessment. While it can be used anytime, and with any couple, it is optimal when used prior to marriage to help couples assess relational strengths and major challenges. Regardless of whether before or during the marriage, the assessment reduces exploratory sessions by providing immediate information for the Christian counselor. The value of the assessment relies on the candid, and trustworthy responses by each participant. This assessment does not predict or forecast success or failure of a relationship. However, it does highlight potential or existing areas where special attention may be required. It further serves as a topical guide to help couples categorize the key elements of their relationship.
Confidentiality: The results of this assessments are strictly confidential, and can only be released by the written consent of the counselee who completes the assessment.
Assessment Fee: Participants may take the assessment at any time. However, an assessment fee of $25.00 is required to receive the results. You will be provided the opportunity to submit an electronic check at the end of this assessment:
Counselor of Record (if any): Counselor's Email:
Personal Information:
Counselee (person taking assessment):
Spouse:
Date:
Email address of counselee:
Divorce Proclivity
Answer the questions where applicable.
1. If you are a divorcee, did you divorce your ex-spouse? Yes No
2. What was the actual reason for the divorce.
3. If your new spouse is divorced, what was the actual reason for your spouse's dissolution
4. Biblically, what are acceptable reasons for divorce?
Christian Life Component
5. Is your new spouse a believer? yes no
6. How often does your new spouse attend church?
1 Sunday per month
2 Sundays per month
3 Sundays per month
4 Sundays per month
7. How often does your new spouse attend Bible Study? (Other than Sunday)
1 day per month
2 days per month
3 days per month
4 days per month
8. Which church or ministry auxiliary does your new spouse work in?
Choir
Ushers
Sunday School
Youth Worker
Deacon
Minister
Other
9. How often does your spouse take special time to read the Bible. 1/Weekly 2/Weekly 3/Weekly 4/Weekly More 1/Monthly 2/Monthly 3/Monthly When possible
9. How often does your spouse take special time to read the Bible.
1/Weekly 2/Weekly 3/Weekly 4/Weekly More 1/Monthly 2/Monthly 3/Monthly When possible
10. How often does your spouse take special time to pray?
11. How often do you attend church?
a. 1 Sunday per month
b. 2 Sundays per month
c. 3 Sundays per month
d. 4 Sundays per month
12. How often do you attend Bible Study? (Other than Sunday)
a. 1 day per month
b. 2 days per month
c. 3 days per month
d. 4 days per month
13. Which church or ministry auxiliary do you work in?
14. How often do you take special time to read your Bible?
15. How often do you take special time to pray?
Financial Stewardship Component
16. Are you currently working? yes no
17. Is your spouse currently working? yes no
18. Do you have child support? Yes No
19. Does your spouse have child support? Yes No
20. Who makes the most net income after any spousal or child support payments? Husband Wife
21. What is your estimation of your financial position with both of your resources combined? (both incomes)
Without using credit cards or getting a loan:
It will be tight but we should be able to pay our bills
We will be able to pay our bills
We will be able to pay our bills, and take a good vacation We will be able to pay bills, add to savings and take a vacation
We will be able to pay our bills, and take a good vacation
We will be able to pay bills, add to savings and take a vacation
We will be able to pay bills, save $200 or more a month, have a good vacation and and Christmas
We have substantial financial resources, money is no problem
Patience, Prayer, and Reflection Component
22. If applicable, how long were you separated before you married (ex: 25 yrs, 3 mos)
23. If applicable, how long was your new spouse separated before he/she married
Ishmael or Step-child Component
24. Will any of your spouse's children be living with you? yes no
25. What is the age of your spouse's children who will be living with you? (example: 5,8,13)
26. What is the age of your children who will be living
with you?
27. How would you describe the relationship between your spouse and his/her step-children (the ones that will be living with you)
Description of Relational Rating. Use as a general guideline:
Exceptional - The spouse provides basic care, plus leads the child in spiritual activities such as prayer, and bible study. Orally, expresses love to the child, and is compassionate. Consistent with discipline, but always providing an opportunity for reconciliation, encouraging growth, and improvement. Always giving the child praise. Respected and admired by the child. The child loves to spend time with the spouse. No more than twice a year, you find yourself between the two, or wishing you could resolve issues between the two.
Good - The spouse provides basic care, plus leads the child in a spiritual growth activity. Orally, expresses love to the child, and is compassionate. Consistent with discipline. Occasionally, praises the child. The child likes to be with the spouse Every few months you find yourself between the two, or wishing you could resolve issues between the two. Fair - The spouse provides basic care, may or may not lead the child in an area of spiritual growth. Has little or nothing to do with discipline, or discipline is harsh and inconsistently applied. The child is indifferent concerning the spouse's presence or prefers not to be around the spouse. Monthly, you find yourself between the two, or wishing you could resolve issues between the two.
Poor - The spouse provides basic care. The spouse tolerates the child. The child tolerates the spouse. They have few memorable times together. Weekly, you find yourself between the two, or wishing you could resolve issues between the two
28. How would you describe the relationship between you and your step-children (the ones living with you). Use the description above:
Relational Rating: Child1 Child2 Child3 Child4 Child5 Child6 Exceptional Good Fair Poor Don't Know 29. Of the children not living with you, have any of them experienced domestic problems where they are currently living? yes no Was not so, or Divorce Imprinting Component 30. Did your spouse's mom or dad divorce before he/she was born or while he/she lived with them? yes no 31. Did your mom or dad divorce before you were born or while you lived with them? yes no
29. Of the children not living with you, have any of them experienced domestic problems where they are currently living? yes no
Was not so, or Divorce Imprinting Component
30. Did your spouse's mom or dad divorce before he/she was born or while he/she lived with them? yes no
31. Did your mom or dad divorce before you were born or while you lived with them? yes no
32. How many times has your spouse's mom divorced
33. How many times has your spouse's dad divorced
34. How many times has your mom divorced
35. How many times has your dad divorced
36. What do your parents or guardians think about your spouse?
Exceptional
Good
Fair
Poor
Don't Know
Parents Deceased
37. What do your spouses parents or guardians think of you?
Do it or Normative Inputs
38. What do your closest friends and kin think of your spouse?
39. What does your spouses closest friends and kin think of you?
Educational Yoke Component
40. What level of education did you complete?
Grade School High School 1-2 College 3-4 College Graduate School Post Graduate School
41. What level of education did your spouse complete?
Gentile or Ethnicity Component
42. What race is your spouse?
43. What is your race?
In your name or Religious Component 44. What denomination or religion is your spouse?
In your name or Religious Component
44. What denomination or religion is your spouse?
45. How long has your spouse belonged to that denomination
46. What denomination or religion did your spouse belong to previously
47. What denomination or religion do you belong to?
48. How long did you belong to that denomination
49. What denomination or religion did your spouse belong to previously Seek Ye First or Future Prospective Component 50. What are your top 3 goals for the next 5 years. 51. What are your top 3 goals for the next 6 - 10 years. 52. What are your spouse's top 3 goals for the next 5 years.
49. What denomination or religion did your spouse belong to previously
Seek Ye First or Future Prospective Component
50. What are your top 3 goals for the next 5 years.
51. What are your top 3 goals for the next 6 - 10 years.
52. What are your spouse's top 3 goals for the next 5 years.
53. What are your spouse's top 3 goals for the next 6-10 years.
54. On any other subject what are you and your spouse's most serious differences.
55. What are you and your spouse's greatest strengths
Do Not Get Drunk or Substance Dependency Component: 56. How much do you drink OR use legal prescription drugs? (anti-depressants, stimulants, etc.)
Do Not Get Drunk or Substance Dependency Component:
56. How much do you drink OR use legal prescription drugs? (anti-depressants, stimulants, etc.)
On special occasions
At least once a week
Probably once a month Rarely
Probably once a month
Rarely
Never
Almost Daily
57. How much does your spouse drink?
Temple of the Spirit or Health Component
58. Do you smoke? yes no
59. Does your spouse smoke? yes no
60. Which of the following do you or your spouse have? You Spouse Diabetes Diabetes Arthritis Arthritis Cancer Cancer Heart Disease Heart Disease Asthma Asthma Migraines Migraines Other Other
60. Which of the following do you or your spouse have?
You Spouse
Conjugal Response Component or Sexuality (yes or no)
61. Do you believe that your libido or sexual drive is satisfactory? Yes No
62. If applicable, in your prior marriage, did your ex-spouse complain concerning your sexual activities? Yes No
63. Did you have any complaints with your ex-spouse concerning sexual activities? Yes No
64. Are you aware of any personal "dysfunctionality" that you have? Yes No
65. Are you aware of any sexual "dysfunctionality" in your spouse? Yes No
66. Are you able to discuss sexuality with your spouse (are you able to discuss what is and is not pleasurable) Yes No
Boaz Insight or Age Component
67. How old are you?
68. How old is your spouse?
Intangibles
69. If you or your spouse participate in gambling activities how much do you spend on an average:
10% or more Ex. Income $1000.00, 100 gambling
5% Ex. Income $ 500.00, 25 gambling
1% of income Ex. Income $ 250.00, 2.50 gamb.
Less than 1% Ex. Income $ 125.00, 1.00 gamb.
Don't Gamble (including Lotto)
70. How often do either of you become involved in disputes
with ex's, friends, relatives, acquaintances, IRS, legal matters, bill collections, etc.?
2 per month
1 per month
1 per 6 months
1 per year
71. How often do either of you travel alone (e.g. business, work etc.)
72. Do either of you have separate hobbies or interest which separate you (Golf, associations, out with the boys or girls, etc.: A day is equivalent to an eight hour period.)
3 days per month 2 days per month 1 day per month ELECTRONIC CHECKING INFORMATION FOR THE ASSESSMENT Please write your name as presented on your checks. Please give a check number. Be sure to record this electronic check in your records, and void the actual check. Please provide the routing number of your check. This is the first series of numbers located near the bottom of your check. Please provide the checking account number. This usually follows the routing number. What is the name of your bank or financial institution? Amount of the check: PLEASE INDICATE ONE OF THE SELECTIONS BELOW: I authorize a check for 25.00 I do not authorize a check
ELECTRONIC CHECKING INFORMATION FOR THE ASSESSMENT
Please write your name as presented on your checks.
Please give a check number. Be sure to record this electronic check in your records, and void the actual check.
Please provide the routing number of your check. This is the first series of numbers located near the bottom of your check.
Please provide the checking account number. This usually follows the routing number.
What is the name of your bank or financial institution?
Amount of the check:
PLEASE INDICATE ONE OF THE SELECTIONS BELOW:
I authorize a check for 25.00
I do not authorize a check
67.
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