Occult Activities and Manifestations Survey
  
 

Name:___________________________ Identification Number:___________

PART II

For the following activities and organizations, please indicate with codes provided, any involvement in, or contact with, those involved in these activities.  If no contact or involvement, circle "no". If unsure, circle "unsure". Circle either PEI or CRI in column #3 for all known contact/involvement.

PERSONAL INVOLVEMENT = PEI      CLOSE RELATIVE INVOLVED = CRI

1.   Survivor of satanic/sadistic ritual abuse No Unsure
PEI / CRI
2.   Survivor of physical abuse No Unsure
PEI / CRI
3.   Survivor of sexual abuse No Unsure
PEI / CRI
4.   Survivor of emotional abuse No Unsure
PEI / CRI
5.   Alcohol use/abuse/addiction No Unsure
PEI / CRI
6.   Other drug use/abuse/addiction No Unsure
PEI / CRI
7.   Tarot cards No Unsure
PEI / CRI
8.   Ouija board No Unsure
PEI / CRI
9.   Seances No Unsure
PEI / CRI
10.  I Ching No Unsure
PEI / CRI
11.  Table tipping No Unsure
PEI / CRI
12.  Parapsychology No Unsure
PEI / CRI
13.  Astrology No Unsure
PEI / CRI
14.  Palm reading/fortune telling/psychometry No Unsure
PEI / CRI
15.  Use of crystals/"crystal hypnosis"/"crystal dreaming" No Unsure
PEI / CRI
16.  Adherent of "A Course in Miracles" No Unsure
PEI / CRI
17.  Other "new age" philosophy/practice No Unsure
PEI / CRI
18.  Santeria No Unsure
PEI / CRI
19.  Voo Doo No Unsure
PEI / CRI
20.  Yoga No Unsure
PEI / CRI
21.  Channeling No Unsure
PEI / CRI
22.  Shamanism No Unsure
PEI / CRI
23.  Psychic healing or other psychic practices No Unsure
PEI / CRI
24.  Contact with psychics No Unsure
PEI / CRI
25.  Runes No Unsure
PEI / CRI

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Copyright 1996 Rex W. Rosenberg
All Rights Reserved