ST3 - PC Information Sheet

PC INFORMATION SHEET

(White Form)

Who Does the Interview? It's done by the Auditor assigned to audit the pc.

When is Interview Done? This interview form is done at the beginning of auditing. It can be redone at a later time if the pc hasn't been audited for a long time. Things can have changed and pc's memory can have improved.

Is this part of the Preclear's Auditing time? Yes, it is. It is important basic information. Although more an interview than formal auditing the information is still being used in auditing processes.

Purpose of Preclear Info Sheet? The Auditor get familiar with the pc and it establish ARC and control. and the form provides essential information needed. The sheet is kept in the pc's folder and reviewed by the case supervisor.

Make sure it is readable. The INFORMATION is needed. You only ask pc the questions that apply to him/her. If you are not sure: Ask pc. (like: you don't ask 'date of death', when the person is still living).

Auditor can use additional paper and mark the letter and number of the question and attach it with a paper clip to this form, if needed.

Date _______________________

Name of PC ___________________________________ Age of PC __________________

Auditor _______________________________________

TA Position at Start ______________________________________________

A. FAMILY

1. Is your mother living? _________________ Meter Read ___________________

2. (Date of Death) _____________________ Meter Read ___________________

3. How is your relationship with your mother? ___________________________________

___________________________________________________________________________

_________________________________________ Meter Read ___________________

4. Is your father living? __________________ Meter Read ___________________

5. Date of Death _____________________ Meter Read ___________________

6. How is your relationship with your father? ___________________________________

___________________________________________________________________________

_________________________________________ Meter Read ___________________

7. Do you have any brothers, sisters or close relatives? (Date of death if any are. and Meter Read:)

Relation/ Date of death/ Meter Read

__________________ __________________ __________________

8. Who do you live with? ________________________________________

___________________________________________________________________________

9. Are you currently associated with anyone who is antagonistic to mental or spiritual treatment or ST? ( if yes, who? )

___________________________________________________________________________

B. MARITAL STATUS:

1. Married? ________ Single?_______ Married before?______________

2. (If divorced: How is your relationship with your ex-spouse?) _______________________________

___________________________________________________________________________

_________________________________________ Meter Read___________________

3. Are there any difficulties in your marriage?_________________________________

_________________________________________ Meter Read___________________

4. If divorced: What were the reasons for the divorce? How do you feel about the divorce?

___________________________________________________________________________

_________________________________________ Meter Read___________________

5. Do you have any children, (date of death of any child):

Children/ Date of Death /Meter Read

__________________ __________________ __________________

C. EDUCATIONAL LEVEL:

What education or professional training have you had? (University, prof. training, etc.)

___________________________________________________________________________

_________________________________________ Meter Read___________________

D. PROFESSIONAL LIFE:

Which main jobs have you held?

Job/ Meter Read

________________________________________________ _______________

E. ACCIDENTS:

Have you had any serious accidents? (if yes: date, character, any permanent damage.)

Accident /Date /Physical damage /Meter Read

__________________ ___________ ___________________ _________________

f. ILLNESSES:

Have you had any serious illness (not usual childhood diseases like colds, etc. ) (date, permanent damage).

Illness/ Date/ Physical Damage/ Meter Read

__________________ ___________ ___________________ _________________

G. OPERATIONS:

Have you had any operations, (if yes: the date of each.)

Operation Date Meter Read

______________________ ______________________ _____________________

H. PRESENT PHYSICAL CONDITION:

Do you have any bad physical condition at the present?

Physical Condition Meter Read

_________________________________________________ __________________

I. MENTAL TREATMENT:

Have you had any psychiatric, psycho-analytic, hypnotic treatment, done mystical or occult exercises, or other mental treatment? (if yes: which, with date(s) and Read(s).)

Treatment /Date/ Meter Read

______________________ ______________________ ____________________

______________________ ______________________ _____________________

J. DRUGS:

Are you taking any drugs currently?

What Drug/ Date/ how long/ Meter Read

______________________ ______________________ _____________________

Have you ever taken drugs?

What Drug/ Date/ how long/ Meter Read

______________________ ______________________ _____________________

K. DISABILITY PAYMENT OR PENSION:

Are you receiving any disability payment or pension? (what for, how much, for how long.)

What for How much Duration Meter Read

__________________ __________________ ___________ ________________

L. ANY FAMILY HISTORY OF INSANITY:
Are there any instances of insanity in the family?

Who /What/ When/ Meter Read

__________________ __________________ ___________ ________________

M. MEDICINES:

What medication, if any, do you take currently? /in the past? (including pain killers).

What/ When/ Meter Read

______________________ ______________________ _____________________

N. EYES: Meter Read

Eye color __________________Color Blindness ______________________

Glasses ______________________ _____________________

O. BODY WEIGHT: Meter Read

Overweight? __________________________________ _____________________

Underweight? __________________________________ _____________________

P. ANY PERCEPTION DIFFICULTIES: Meter Read
Do you have any perception difficulties? (sight/hearing/smell/taste, etc.)

______________________________________________ _____________________

Q. ANY PERCEPTION TROUBLE IN FAMILY: Meter Read

Are there any perception difficulties in the family?

______________________________________________ _____________________

R. SICK OR DISABLED FAMILY: Meter Read

Do you have sick or disabled family?

______________________________________________ _____________________

______________________________________________ _____________________

S. EARLIER ALLIES OR CLOSE FRIENDS: Meter Read

Tell what earlier close friends and supportive people you have had.

______________________________________________ _____________________

______________________________________________ _____________________

T. SPOUSE'S PHYSICAL TROUBLE Meter Read

Does your spouse have any physical troubles?

______________________________________________ _____________________

U. ATTITUDE TOWARDS ILLNESS: Meter Read

What is you attitude toward illness?

______________________________________________ _____________________

W. ANY CURRENT TREATMENT IN PROGRESS Meter Read

Are you receiving any medical or other kind of treatment?

______________________________________________ _____________________

X. COMPULSIONS, REPRESSIONS & FEARS:

Are there anything you MUST do (compulsions)?
Are there anything you must prevent yourself from doing?

Is there anything you must not think about (repressions)
Do you have any fears?

Compulsions , etc Meter Read

______________________________________________ _____________________

Are you trying to change something someone else doesn't like?

_____________________________________________________________________

Y. CRIMINAL RECORD:

Do you have a criminal record or have you committed crimes?
List any crime committed by PC, prison sentence, if any , and Meter Reads:

Crime/ Sentence/ Meter Read

______________________ ______________________ _____________________

Z. INTERESTS AND HOBBIES: Meter Read

What are your interests and hobbies?

______________________________________________ _____________________

ARE YOU HERE ON YOUR OWN FREE WILL?

______________________________________________ _____________________

AA. ANY PREVIOUS PROCESSING (Scn, Dianetics™, ST, Freezone)

1. List auditors, hours, and Read to any processing done and where.

Auditor/ Hours/ Meter Read

______________________ ______________________ ______________________

2. List briefly processes run ___________________________________________

_____________________________________________________________________

3. What did you get out of this processing _______________________________

_____________________________________________________________________

BB. PRESENT PROCESSING GOALS:

What are your present goals for processing (get complete list)

Goal/ Meter Read

______________________________________________ _____________________

Tone Arm position at end of Interview _______________________________