Inner Healing Intake FormIf you are scheduled for an in-person, local, inner healing appointment, please complete the form below. Name First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home PhoneCell PhoneEmail Date of Birth MM slash DD slash YYYY Is your relationship with Jesus: Vibrant Strong Nominal Shaky None Denomination: Are you baptized in the Holy Spirit? Yes No Marital Background Married Divorced Widowed Single If married please rate your marriage on a scale of 1 to 5, 1 being extremely dissatisfied, 5 being extremely satisfied: 1 2 3 4 5 Date of Marriage MM slash DD slash YYYY If currently married, have you previously been divorced or widowed? Yes No ChildrenI've had one or more abortions. Yes No If yes, how many? I've had one or more miscarriages. Yes No If yes, how many? I've had one or more stillbirths. Yes No If yes, how many? I've had one or more children pass away. Yes No If yes, how many? Please list name and ages of living children/ stepchildren:Describe your relationship with your children/ stepchildren:Describe your current living situation:Ministry Request InformationWhat do you want Jesus to do for you in this prayer ministry session?How does this issue leave you feeling about yourself?How does this issue leave you feeling about God/ your relationship with Him?How does this affect those you love?Have you received inner healing, regarding this issue, in the past? Yes No Are you currently seeing a counselor or mental health professional? Yes No Are you currently on medication for mental health? Yes No If you answered yes to any of those questions, please elaborate here:Check the issues that pertain to you. Depression Marital Problem(s) Drug Addictions Eating Disorder Grief/ Loss Occult Oppression Workaholism Unforgiveness/ Bitterness Premature Deaths Pride Unworthiness Blocked Emotions Chronic Illness Same Sex Attraction Same Sex Relationships Insomnia Alcoholism Low Self-Esteem Career Instability Financial Crisis Excessive Anxiety Suicidal Thoughts Rebellion Shame/ Guilt Withdrawal Sexual Identity Issues Anger Physical Abuse Sexual Abuse Emotional Abuse Relationship Issues Loneliness Fear Abandonment Rejection Trauma Neglect List any word curses or inner vows you've said to yourselfList any word curses spoken about you by othersFamily Background InformationDescribe your relationship with your father, both as a child and now:How did/does he show love?Describe your relationship with your mother, both as a child and now:How did/does she show love?Check all that apply: I don't remember being loved physically as a child (hugs, being held, etc.). My parents divorced when I was a child. I was sexually abused by a parent or stepparent. I was physically and/ or sexually abused from a non-parental family relationship. I was physically and/ or sexually abused from someone not in the family. I was ＿＿ old when parents divorced. What is your family's ethnic background? Describe your family (including extended) cultural normsIdol/ Occult HistoryHave you ever had your fortune told, had a palm reading, used a crystal ball, consulted tarot cards, followed or read your horoscope? Yes No Have you ever played with a Ouija board? Yes No Have you ever practiced automatic writing? Yes No Have you ever practiced yoga or transcendental meditation? Yes No Have you ever communicated with apparitions that were not of God, including but not limited to attending a seance or a spiritualist meeting? Yes No Have you ever played Dungeons and Dragons, black or white magic games, or played with a voodoo doll? Yes No Do you have any objects(s) or book(s) in your possession that may bring an evil presence or influence with it? Symbols? Dolls? Kits? Yes No Have you ever cast spells? Yes No Have you ever practiced table-lifting, levitation of objects or bodies, or astral travel? Yes No Have you ever worshipped a shrine or object? Yes No Have you ever attended a satanic meeting, voodoo meeting, coven meeting or belonged to a coven? Yes No Have you ever made a promise, pact or blood pact with Satan? Yes No Are you a victim of Satanic Ritual Abuse? Yes No Witnessed or participated in a sacrifice (with or without blood) to any entity or spirit? Yes No Have you been a member of the Masons, Christian Science, Rosicrucian, Jehovah's Witness, Gurus, Mormons, Unification Church, Unity, Scientology, Native Religions? Yes No Have you been in an intimate relationship with someone involved in witchcraft? Yes No Have your parents or ancestors been involved in witchcraft? Yes No Have your parents or ancestors been a member of the Masons? Yes No Have you willingly been involved in any addictive or ongoing sin that could bring about oppression in your life such as pornography, drugs, infidelity, ect.? Yes No Any final notes you think would be important for your ministers to know:Days Available: Monday Tuesday Wednesday Friday Times Available: 10 am - 1 pm 1 pm - 4 pm 4 pm - 7 pm
