1.Overall how would you rate your physical health?

Excellent

Very good

Good

Fair

Poor

2.How interested are you in knowing God and His will better?

Extremely interested

Very interested

Somewhat interested

Not so interested

Not at all interested

3.Do you think you have any type of addiction and could use some help?

Strongly agree

Agree

Neither agree nor disagree

Disagree

Strongly disagree

4.How willing are you to do what it takes to improve your life?

Definitely would

Probably would

Probably would not

Definitely would not

5.Do you believe God loves you, and He has a plan for your life? And that He sacrificed His Son Jesus for payment of our sins, and that we need to accept Jesus as our Lord and Savior to benefit from His sacrifice. And do you want to learn more how God can help you now, and be with you in heaven when you die?

Yes

No

Other (please specify)