EmpowerHER Inquiry Form

EmpowerHER Inquiry Form

Please be detail with this form so we can assess your needs and provide the best services possible tailored to your needs. r
Name

First NameLast Name
Date of Birth

MonthDayYear
Age
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number

Area CodePhone Number
What is your Time Zone?
What is the best time to call for a consultation?
If you are from a country other than the United States, Please provide us with the number you use for WhatsApp.
Marital Status
Occupation
Educational status
Do you have children? If so please list the names of your children.
Ethnicity ID:
Race ID: I identify as(Only answer if you do not Identify as Hispanic or Latino)
Emergency Contact: Please list name, phone number, and address
Name of Church Home and address
Referred by:
What is your perception of who you are as a woman?
List at least three achievements you have had in your life, particularly as a woman.
List Three Traumas or challenges you have had in your life particularly as a woman.
List three areas of empowerment you need from this mentoring group.
List three areas of empowerment you need from the leader in this group.
Where would you like to see yourself in six months in life and as a woman?
Listed below are common triggers, please check one or more boxes of things that trigger or “push your buttons.” Ask the Lord to highlight any additional triggers and record them below*
List any additional triggers, frustrations, or challenges you have

Are you adopted?
Please place a check mark for acknowledgement
Signature
EmpowerHER and KINGDOM WELLNESS COUNSELING & MENTORING CENTER AGREEMENT

(Acknowledgement of services)
I understand the following:

If I "no show" for an appointment, I will not be able to reschedule except in cases of extreme emergency. It is is imperative that I honor my time and commitment to my dreams and progress. If I " no show" it is my responsibility to initiate the scheduling of my next session. My Counselor (or mentor, consultant, coach) will not be initiating the rescheduling of "no show" sessions. A $25 fee will be added to be rescheduled "no show" sessions and must be paid when I pay for the rescheduled session.Though Priase Asemota and Dr. Taquetta Baker are Apostles and deliverance ministers, they do not claim to be or operate as a personal apostle or minister to clients who receive Services. Neither does any of the counselors, deliverance, and inner healing workers that are part of her team. Our role is to provide a biblically based counseling, deliverance, or inner healing service so people can be set free.Clients may be encouraged to partake of online or conference call teaching, prayer sessions, and given privy to Prophetic and Apostolic Prayer Watch Alerts that are provided by Praise Asemota, Kingdom Wellness, Kingdom Shifters, Kingdom Shifters Christian Empowerment Center, I understand that this is not for personal relationship or ministry relations. It is to further assist clients in their healing and wellness.
Release of Liability Waiver

Please read and acknowledge understanding by you signature
Waiver: In consideration of being able to participate any services provided by Praise Asemota and Kingdom Wellness Counseling and Mentoring Center, I for myself, my heirs, personal representatives or assigns, hereby release, waive, discharge, and covenant not to sue or hold liable Praise Asemota, Taquetta Baker, Kingdom Wellness Counseling and Mentoring Center, Kingdom Shifters Wellness University, Kingdom Shifters Ministries, Kingdom Shifters Christian Empowerment Center, nor any assigned sponsors, speakers, partners, contractors, affiliates, or any entities connected to these persons, business, or organizations for services provided through Kingdom Wellness. I acknowledge and understand that the information provided by Praise Asemota, Taquetta Baker and ALL Kingdom Wellness Counselors and Workers during any level of service or sessions cannot replace or substitute the services of any professional personnel including medical, psychological, financial or legal and none of the information should be confused as such. Neither Praise Asemota, Taquetta Baker, Kingdom Wellness Counseling & Mentoring Center, Kingdom Shifters Wellness University, Kingdom Shifters Ministries, nor any assigned sponsors, speakers, partners, contractors or any of their affiliates will be liable for any direct, indirect, consequential, special, exemplary or other damages to the Client, Client’s family, life situations, or Client’s business including economic loss, that may result from participation in the Program or from the use or inability to use the materials, information or strategies communicated through the Program. I acknowledge and understand that the Client (person/s receiving services and or guardian), alone are responsible and accountable for the decisions, actions, and results in life, and by their participation in this Program, they agree not to attempt to hold Praise Asemota, Taquetta Baker, Kingdom Shifters Ministries, Kingdom Wellness Counseling & Mentoring Center, or any entities connected to theses persons, business, or organizations liable for any decisions, actions or results that the client may make or experience in your family, business, ministry or life due to your participation in this Program at any time, under any circumstances.
I acknowledge that I have read the above Release of Liability. I acknowledge that I am signing feely and voluntarily this agreement and intend by my signature to be a complete an unconditional release of all liability to the greatest extent of the law.
Please Type full name for acknowledgement
Should be Empty: