Appointment Request Form
Inner Healing Appointment Request
Full Name (must be 18 years or older)
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First Name
Last Name
Gender
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Please Select
Male
Female
Contact Number
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Please enter a valid phone number.
Email Address
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example@example.com
Preferred Method of Communication
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Please Select
phone call
text message
email
Your Availability? (Please plan for a 2 hour block of time)
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Preferred days of week or times of day, e.g. Tuesdays and Wednesdays after 2 pm
HOW SOON WILL I BE CONTACTED? Our goal is to contact you within a week of receiving your application, and to have your session within 30 days of your application. Our Inner Healing team consists of all volunteer ministers who are trained in Inner Healing tools and process. We will do our very best to fit your timing and personal needs as soon as possible for our team.
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I understand and agree
How did you find out about Lighthouse Church Inner Healing Ministry?
Church Attending?
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Prayer ministers gender preference. Two or three people will be in the session with you. We want you to be comfortable and open to sharing.
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Males only
Females only
No preference - a mixed male-female team is ok with me
Are you a counseling client of Karen O'Brien?
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Yes
No
Do you have a request for a specific team member to be on your prayer team? If so, please select their name(s)
Lori
Karen
Daiquiri
Luke R
David
Ruth
Trina
Tina
Travis
Ronnell
Is there any member of our prayer team that you would rather NOT have on your prayer team (this helps us assign a team & will not be shared with the prayer team)?
Lori
Karen
Daiquiri
Luke R
David
Ruth
Trina
Tina
Travis
Ronnell
Which drugs are you taking - Rx or otherwise?
Do you feel you are addicted to anything at this time?
Prescription Drugs
Other Drugs
Alcohol
Sex
Pornography
Shopping
Food
Exercising
Intellectualizing
Avoidance
Fantasy
Other
If "other", list addiction
Please click the box below to expand it so you can see all (5) sections. I acknowledge that I have read the disclaimer, release of liability, and privacy notes below. I understand and agree with it. By submitting this form, I am executing it as my free and voluntary act.
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Please Select
I understand and agree
(1) I ACKNOWLEDGE that members from Lighthouse Christian Church have voluntarily agreed to pray for me. I understand that this session is not a professional counseling meeting. 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 Lighthouse Christian Church is a nonprofit corporation that makes no charge for its services. I further state that I have voluntarily sought assistance of my own initiative and that I'm under no obligation to accept or reject any of the advice or help that I might receive from the team members of this church. Lighthouse Christian Church offers Biblical spiritual services to anyone who desires them regardless of ability to pay. (2) CONFIDENTIALITY: there are limits to confidentiality that are to be adhered to by the prayer team members. The most common of these exceptions are when there is a real or potential life or death emergency, when the court issues a subpoena, or when child or vulnerable adult abuse or neglect is involved. If you communicate to a prayer minister an explicit threat to kill or inflict serious bodily injury upon a reasonably identifiable person, and you have the apparent intent and ability to carry out that threat, Lighthouse Christian Church has a duty to take reasonable precautions. These precautions may include disclosing relevant information you have provided, which is essential to protect the rights and safety of yourself and/or others. (3) I UNDERSTAND that if I receive ministry from Lighthouse Christian Church, the team is committed to respect the disclosed information, but not to complete confidentiality. The information, as needed, may be shared with other leaders of Lighthouse Christian Church so as to further my total healing process. This may include future meetings with spiritual mentors in the church to set appropriate boundaries for my personal and spiritual growth. (4) NOTE: FOR THE SAFETY OF ALL PERSONS VISITING LIGHTHOUSE CHRISTIAN CHURCH CAMPUS, PLEASE BE AWARE THAT OUR CONFERENCE ROOMS AND OFFICES MAY HAVE CAMERAS WITH VIDEO AND SOUND CAPABILITY. ACCESS TO RECORDINGS IS LIMITED TO THE HIGHEST LEVEL OF CHURCH LEADERSHIP AND ARE ONLY VIEWED WHEN AN EXIGENT MATTER EXISTS. I AGREE TO HOLD LIGHTHOUSE CHRISTIAN CHURCH AND ITS TEAM MEMBERS FREE FROM ANY AND ALL LIABILITY, LOSS OR DAMAGE OF ANY KIND THAT MAY ARISE AS A RESULT OF THE ASSISTANCE WHICH I HAVE RECEIVED, OR FROM MY INVOLVEMENT WITH LIGHTHOUSE CHRISTIAN CHURCH. (5) I have read this disclaimer and release of liability and understand and agree with it and have executed it as my free and voluntary act.
Submit
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