Today's Date *

MM

DD

YYYY

Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Best Phone Number *

(###)

###

####

Emergency Contact Name *

First Name

Last Name

Emergency Phone

(###)

###

####

Marital Status *

Single

Married

Divorced

Widowed

Were you raised by anyone other than your parents? *

Yes

No

What struggles are you currently facing?

Mental Health Concerns (panic attacks, bipolar disorder, schizophrenia, depression, suicidal thoughts, etc.)

Grief & Loss

Drug Use

Alcoholism

Physical Illness

Occult/Witchcraft

Financial Concerns (gambling, overspending)

Relationships

Pornography

History of Trauma and/or Abuse

Domestic Violence

Other

Have you accepted Jesus Christ into your life? *

Yes

No

Have you ever experienced deliverance or inner healing? *

Yes

No

Have you been baptized in the Holy Spirit? *

Yes

No

Were you raised as a Christian? *

Yes

No

Are you currently seeing a counselor/therapist? *

Yes

No

Are you currently being prescribed medications? *

Yes

No

Have you ever been hospitalized for a psychiatric condition? *

Yes

No

Name *

First Name

Last Name

Today's Date *

MM

DD

YYYY