Please enable JavaScript in your browser to complete this form.Personal Information - Step 1 of 5Name *FirstLastEmail *Phone *Birthdate *NextMarital Status *SingleMarriedSeparatedDivorcedWidowedIf currently in a romantic relationship or are seperated/divorced/widowed describe your relationship with that person. Do you have children? *yesnoIf so, what are your children's names and ages? Briefly describe you relationship with each.Are there any unhealthy patterns in your home that you would like to see freedom in?Were you born out of wedlock? *Yes NoI don't knowAre your parents still married? *Yes NoI don't knowIs your father still living? *Yes NoI don't knowIs your father a Christian? *Yes NoI don't knowIs your mother still living? *Yes NoI don't knowIs your mother a Christian? *Yes NoI don't knowDescribe your relationship with your parents:Do you have siblings? If so how many and describe your relationship with each:In whose home were you raised? *Both biological parent'sMother's homeFather's homeGrandparent's homeAdoptive parent's homeFoster Home(s)Family friend's homeOrphanageOther relative's homeWere you raised in a Christian home? *Yes NoI don't knowWas there abuse of any kind in your home? If so, briefly describe.Was your upbringing in an alcoholic or drug dominated home? If yes, please briefly explain.Is there anything else you would like us to know about your upbringing?NextDenominational Preferencei.e. Baptist, Catholic, Non-denominational.What church do you presently attend?Who is your pastor?Who currently disciples you?Are you Saved? *YesNoNot SureIf you have had a salvation experience, briefly describe your conversion and how your life changed after that point.Are you plagued with doubt about your salvation? *YesNoNot SureHave you been baptized into the Holy Spirit? If so please give brief description of your experience.How often do you read your Bible?OftenOccasionallyNeverDo you pray regularly?YesNoDo you find it difficult to pray? If so, explain.When attending Christian meetings are you plagued with foul thoughts, jealousies, rejection, or other mental harassment? If so, explain.Have you or any of your family had any involvement in the following:Freemasonry (Masonic Lodges)Eastern StarJob's DaughtersOddfellowsShrinersDaughter of the NileRainbow GirlsElks ClubKu Klux KlanDemolayAmerican FederationOtherIf you checked any of the above, state who, when, and to what extent.Have you ever had any involvement with the following:Fortune TellingClairvoyanceAstral ProjectionCrystalsAstrologyAutomatic WritingSpirit GuidesMediumsPalm ReadingWhite magicNew Age Movement or PracticesHoroscopesWitch DoctorsNative healersEnergy WorkBlack magicReikiTarot CardsWhite MagicQuija BoardDemon WorshipAngel WorshipSeancesOtherDescribe your involvement with any of the above:NextAre you experiencing any of the following? Check all that apply.Third ChoiceShameFearPanisNeglectPerformanceBitternessHatredAdulterySuicideUnworthinessBlasphemous ThoughtsRebellionLonelinessConfusionGuiltWorrySelf-RejectionUnwantednessResentmentFantasyLustDeath WishInadequacyPrideDoubtCompulsivenessDeception (lies)AnxietyControlAngerDepressionComparisonPornographyAbuseInferiorityArroganceSkepticismAddictionsIf you checked any of the above give an explanation to it below.Are there any other areas that you would like freedom in? NextThis ministry is called prayer ministry. It is not professional counseling. We work with you only as you choose to work with us. We are strictly Christians seeking the Lord in prayer on your behalf. God has seen fit to work with and through us in moving people toward freedom from spiritual, emotional, and even physical problems. Therefore, it is our expectation that He will help you through our time together. But we cannot control God or promise what He will do. We can only promise that we will do our best to work with God for your good and God's glory. Name *FirstLastDate / *Signature *Clear SignatureSubmit