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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 (years). It is specifically the first step of Grade 5, Engram Clearing, where the complaints at the time it is done, will be directly addressed with Engram Clearing techniques.
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? ________________________________________
___________________________________________________________________________
Note name/Meter read on these as minimum.
9. Are you currently associated with anyone who is
antagonistic
to mental or spiritual treatment or ST? ( if yes, who?) __________________
10. Is anyone actively objecting to your getting treatment? __________________
11. Has anyone insisted on you getting treatment? __________________
12. Has anyone ever objected to your getting treatment? __________________
13. Has anyone encouraged you to get treatment? __________________
14. Has anyone ever objected to you getting better? __________________
15. Has anyone ever assisted you in self-betterment? __________________
16. Does anyone not like you the way you are? __________________
17. Has anyone tried to make you change or be different? __________________
B. MARITAL STATUS:
1. Married? ________ Single?_______ Married before?______________
2. How is your relationship with your 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, professional training, etc.)
___________________________________________________________________________
_________________________________________ Meter Read___________________
D. PROFESSIONAL LIFE:
Which main jobs have you held?
Job/ Meter Read
________________________________________________ _______________
________________________________________________ _______________
________________________________________________ _______________
________________________________________________ _______________
E. DRUGS: (LIST DRUGS, MEDICINE OR ALCOHOL TAKEN THIS LIFETIME)
1. Are you taking any drugs currently?
What Drug Date (How Long) E-Meter Reaction
__________________ __________________ __________________
__________________ __________________ __________________
__________________ __________________ __________________
__________________ __________________ __________________
__________________ __________________ __________________
__________________ __________________ __________________
2. Have you ever taken drugs?
What Drug/Date (How Long)/Read
__________________ __________________ __________________
__________________ __________________ __________________
__________________ __________________ __________________
__________________ __________________ __________________
__________________ __________________ __________________
__________________ __________________ __________________
3. Are you taking/drinking any alcohol or alcoholic drinks
currently?
What Alcohol/ Date (How Long)/Read
__________________ __________________ __________________
__________________ __________________ __________________
__________________ __________________ __________________
__________________ __________________ __________________
__________________ __________________ __________________
__________________ __________________ __________________
4. Have you ever used alcohol or alcoholic drinks?
What Alcohol/Date (How Long)/Read
__________________ __________________ __________________
__________________ __________________ __________________
__________________ __________________ __________________
__________________ __________________ __________________
__________________ __________________ __________________
__________________ __________________ __________________
5. List any medicine currently or previously taken.
What/When/Read
__________________ __________________ __________________
__________________ __________________ __________________
__________________ __________________ __________________
__________________ __________________ __________________
__________________ __________________ __________________
__________________ __________________ __________________
F. LOSSES:
What severe losses have you had in life that influenced it?
Date/Description/Read
__________________ __________________ __________________
__________________ __________________ __________________
__________________ __________________ __________________
__________________ __________________ __________________
G. DEATHS:
What deaths have severely affected your life?
Date/Person/Read
__________________ __________________ __________________
__________________ __________________ __________________
__________________ __________________ __________________
__________________ __________________ __________________
H. UPSETS:
Are you upset with anything or anyone in the present?
Situation/Person/Read
__________________ __________________ __________________
__________________ __________________ __________________
__________________ __________________ __________________
__________________ __________________ __________________
I. DANGERS:
1. Are you in any particular danger at this time?
Description/Read
__________________ __________________ __________________
__________________ __________________ __________________
__________________ __________________ __________________
__________________ __________________ __________________
2. Are there Engrams that match this in the past?
Description/Reads
__________________ __________________ __________________
__________________ __________________ __________________
__________________ __________________ __________________
__________________ __________________ __________________
J. ACCIDENTS:
Have you had any serious accidents? (if yes: date, character,
any permanent damage.)
Accident /Date /Physical damage /Meter
Read
__________________ ___________ ___________________ _________________
__________________ ___________ ___________________ _________________
__________________ ___________ ___________________ _________________
__________________ ___________ ___________________ _________________
K. ILLNESSES:
Have you had any serious illness (not usual childhood
diseases like colds, etc. ) (date, permanent damage).
Illness/ Date/ Physical Damage/ Meter
Read
__________________ ___________ ___________________ _________________
__________________ ___________ ___________________ _________________
__________________ ___________ ___________________ _________________
__________________ ___________ ___________________ _________________
__________________ ___________ ___________________ _________________
__________________ ___________ ___________________ _________________
__________________ ___________ ___________________ _________________
L. OPERATIONS:
Have you had any operations, (if yes: the date of each.)
Operation Date Meter Read
______________________ ______________________ _____________________
______________________ ______________________ _____________________
______________________ ______________________ _____________________
______________________ ______________________ _____________________
M. PRESENT PHYSICAL CONDITION:
Do you have any bad physical condition at the present?
Physical Condition/Meter Read
_________________________________________________ __________________
_________________________________________________ __________________
_________________________________________________ __________________
_________________________________________________ __________________
N. PT ILLNESSES:
1. Any current illnesses?
Illness/Meter Read
________________________________________________ __________________
_________________________________________________ __________________
_________________________________________________ __________________
_________________________________________________ __________________
2. Do you have any recurring physical ailment?
Illness/History/Meter Read
________________________________________________ __________________
_________________________________________________ __________________
_________________________________________________ __________________
_________________________________________________ __________________
O. 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
__________________ __________________ ___________ ________________
__________________ __________________ ___________ ________________
P. ANY FAMILY HISTORY OF INSANITY:
Are there any instances of insanity in the family?
Who /What/ When/ Meter Read
__________________ __________________ ___________ ________________
__________________ __________________ ___________ ________________
__________________ __________________ ___________ ________________
Q. EYES:
Data/Meter Read
Eye color __________________Color Blindness ______________________
Glasses ______________________ _____________________
R. BODY WEIGHT:
Data/Meter Read
Overweight? __________________________________ _____________________
Underweight? __________________________________ _____________________
S. ANY PERCEPTION DIFFICULTIES: Meter Read
Do you have any perception difficulties? (sight/hearing/smell/taste, etc.)
______________________________________________ _____________________
______________________________________________ _____________________
______________________________________________ _____________________
T. ANY PERCEPTION TROUBLE IN FAMILY: Meter Read
Are there any perception difficulties in the family?
______________________________________________ _____________________
______________________________________________ _____________________
U. SICK OR DISABLED FAMILY: Meter Read
Are there any sick or disabled members of the family?
______________________________________________ _____________________
______________________________________________ _____________________
V. EARLIER ALLIES OR CLOSE FRIENDS: Meter Read
Tell what earlier close friends and supportive people you
have had.
______________________________________________ _____________________
______________________________________________ _____________________
W. SPOUSE'S PHYSICAL TROUBLE Meter Read
Does your spouse have any physical troubles?
______________________________________________ _____________________
______________________________________________ _____________________
______________________________________________ _____________________
X. ATTITUDE TOWARDS ILLNESS: Meter Read
What is you attitude toward illness?
______________________________________________ _____________________
______________________________________________ _____________________
______________________________________________ _____________________
Y. ATTITUDE TOWARDS TREATMENT: Meter Read
What is you attitude toward treatment?
______________________________________________ _____________________
______________________________________________ _____________________
Z. ANY CURRENT TREATMENT IN PROGRESS:
Data/History/Read
Are you receiving any medical or other kind of treatment?
______________________________________________ _____________________
______________________________________________ _____________________
______________________________________________ _____________________
AA. 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?
_____________________________________________________________________
BB. 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
______________________ ______________________ _____________________
______________________ ______________________ _____________________
______________________ ______________________ _____________________
______________________ ______________________ _____________________
CC. INTERESTS AND HOBBIES: Meter Read
What are your interests and hobbies?
______________________________________________ _____________________
______________________________________________ _____________________
______________________________________________ _____________________
DD. ARE YOU HERE ON YOUR OWN FREE WILL (SELF DETERMINISM)?
______________________________________________ _____________________
EE. 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 _______________________________
_____________________________________________________________________
_____________________________________________________________________
FF. "SOMEBODY ELSE"
1. Do you look on yourself as somebody else? (Read/Data)
2. When you see pictures of the past do you see yourself from a distance? (Read)
GG. FORMER PRACTICES:
1. What practices or treatments have you engaged upon in the past?
Practice, Therapy/ Date/Read
______________________ ______________________ ______________________
______________________ ______________________ ______________________
______________________ ______________________ ______________________
______________________ ______________________ ______________________
2. Are you continuing any of the above in the present?
______________________ ______________________ ______________________
______________________ ______________________ ______________________
______________________ ______________________ ______________________
______________________ ______________________ ______________________
HH. "RECURRING PROBLEMS"
What problems are you trying to solve by processing?
______________________ ______________________ ______________________
______________________ ______________________ ______________________
______________________ ______________________ ______________________
______________________ ______________________ ______________________
JJ. ELECTRIC CHOCK
1. Have you ever been given Electric Chock Treatment?
(If Yes) How many times?
2. Were you instructed to come here?
KK. REALITY FACTOR:
You know of course that people sometimes get cross at the auditor or run away when they are withholding information from them and we don't want you to do that.
Anything you tell me is confidential and is protected under ministerial confidence.
Is there anything we have missed or omitted while doing this Assessment? (Carefully note any Meter reads.)
Ask: "Is there anything you would care to tell me about this?"
Tone Arm position at end of Interview _______________________________
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