Living Waters
Please fill out the information below
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Age
Marital Status
Please Select
Single
Married
Separated
Divorced
Widowed
Do you have children? (yes, no, how many and ages)
Are you a christian? (yes, no, how long)
Church affiliation
DIRECTIONS: The spaces provided will expand as needed. Please be specific and provide as much detail as you can.
1. Please describe what you hope to receive from Living Waters.
2. How would you define your relational, emotional or sexual problem(s)? (emotional or codependency, same-sex attraction, addictive behaviors, sexual promiscuity, effects of abuse, impact of any of the above on marriage)
3. How does the problem express itself? (include compulsive non-sexual behaviors)
4. Describe any help you are currently receiving form a healing ministry or support group.
5. Describe the people in your life who know about your struggles and who are supportive of your recovery.
6. How do you feel about giving and receiving healing prayer in a small group setting?
7. Describe your history of pastoral and professional counseling. Include any history with a Living Waters program.
8. Describe your moral position on sexuality, e.g. the parameters for sexual expression. Include your views on homosexual practice.
9. Have you ever seriously contemplated suicide? (yes or no, if yes please explain)
10. Have you ever been convicted of a felony? (yes or no, if yes please explain)
11. The specific dates and schedule of the local program will be provided for you. A commitment to attend every session, with few exceptions, is required. If accepted, are you willing to prioritize your schedule to honor this commitment? yes or no
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