Free People Church

PERSONAL INFORMATION

First Name

Last Name

Email Address

Phone Number

Birthdate

Age

Gender
Male
Female

Marital Status
Single
Married

Emergency Contact Name

First Name

Last Name

Phone Number

SPIRITUAL BACKGROUND

Have you ever prayed to receive Christ for salvation?
Yes
No

Have you ever been baptized in water?
Yes
No

How long have you been saved approximately?

Briefly describe your salvation experience…

Do you regularly attend church?
Yes
No

MINISTRY NEED

What is the main reason you’re seeking ministry or the main thing you’re wanting help with? (Please BRIEFLY explain)

Please describe any “symptoms” associated with this issue, including any physical health problems, mental/emotional issues, relational issues, or demonic oppression/manifestations

When did this difficulty (or these symptoms) start in your life and was there anything negative that happened to you at that time (personally, relationally, etc.)? Briefly Explain.

MENTAL & EMOTIONAL HEALTH

Have you ever attempted suicide or been admitted for psychiatric care?
Yes
No

Have you had any close family or friends commit suicide? (If so, describe relationship)

Do you currently hold anger, bitterness, hatred or resentment against anyone (living or dead) that you know of? If so, briefly explain.

Do you consistently feel any of the following overwhelming negative emotions:
Fear
Anger
Shame
Self-Criticism
Depression/Major Discouragement
Rejection from others

SPIRITUAL HISTORY & INVOLVEMENT

Have you ever been involved in any of the following groups/organizations, or practices (even if just one time, even if it was years ago)?

DELIVERANCE HISTORY

Have you ever been through a personal Deliverance Prayer Session (or inner healing) for yourself? (If so, briefly describe your experience and how effective it was in helping you.)

Are you currently taking any medications for any anxiety, depression, or mental health conditions?
Yes
No

Have you ever been through a personal Deliverance Prayer Session (or inner healing) for yourself? (If so, briefly describe your experience.)

CONSENT AND AGREEMENT FOR SERVICES
I agree to the terms outlined.
I acknowledge that the Spiritual Health Team members from Free People Church have voluntarily agreed to meet and pray for me.
I understand that this session is not a professional counseling meeting or relationship and that none of the team members are acting as licensed counselors.
I understand that these team members are, to the best of their ability, doing what they can to help me achieve more freedom in my life.
I understand that Free People Church is a non-profit Ohio Corporation that makes no charge for its services. I further state that I have voluntarily sought assistance of my own initiative and that I am under no obligation to accept or reject any of the advice or help that I might receive from the team members of this ministry.
I understand that in some instances physical and emotional reactions can result in response to this ministry time.
I understand that the Spiritual Health Team is committed to respect my disclosed information. The information, as needed, may be shared with appropriate leaders at Free People Church, so as to further the total healing process.
I agree to hold Free People Church and its team members free from any and all liability, loss or damage of any kind that may arise as a result of assistance which I have received or from my involvement with the Spiritual Health Team.
I have read this disclaimer/release of liability and understand its terms and agreements. My electronic signature signifies my agreement with it and that I am executing it as my free and voluntary act.

Electronic Signature

By entering your name in this box, you are electronically signing this form and affirming that your consent and agreement are given freely, fully, and truthfully.

Deliverance Prayer

Deliverance Prayer Session Request Form

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