Two Year Ministerial Program Applicant Personal Questionnaire Please print this form. Complete all information and return with application to: Registrar, The New Seminary PMB #344 2576 Broadway New York, New York 10025-5657 (212) 222-3711 PERSONAL QUESTIONNAIRE - THE NEW SEMINARY The New Seminary Training Program includes an in-depth journey of personal discovery which can bring up intense feelings, emotions and memories. This questionnaire is an assessment tool that will help you and us to get to know you better. Please answer to the best of your ability, as this will enable us to support you during your course of studies and facilitate your personal interview. All material is confidential. (Please use back of sheet or second sheet if necessary.) 1. Are you currently experiencing any serious health challenges? ______________________________ _____________________________________________________________________________________ Are you on any medication, please describe:_________________________________________________ 2. Have you ever been or are you now under a psychiatrist’s or psychologist’s care? When? ______ How long? ____________What is the diagnosis?_____________________________________________ Does this in any way affect your ability to function?___________________________ _______________ Are you on, or have you ever been on psychotropic medications while under a psychiatrist’s care? Which medications?______________________________________ How long?______________________ Do these affect your ability to function?_____________________________________________________ 3. Do you have any personal history of abuse? (physical, emotional, sexual, satanic, child) . Please explain: _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ 4. Have you ever been addicted to drugs or alcohol? Please explain____________________________________________________________________________ ________________________________________________________________________________________ What is your current status?_______________________________________________________________ 5. How have any of the above challenges affected your life? _______________________________________________________________________________________ 6. Write a few sentences describing how you perceive yourself. (Use separate page if necessary) _________________________________________________________________________________________ _________________________________________________________________________________________ ___________________________________________________ Contact in case of emergency (name, relationship, address, phone no.) _______________________________________________________________________________________ _______________________________________________________________________________________ I affirm that all the above statements are true. False information can be grounds for dismissal from the New Seminary. If taking psychotropic medication, an additional letter of recommendation is required from your psychiatrist. Print Name __________________________ _______________________________ Date: __________________________ Signature Class: __________________________ Return to the entrance application (click here).