UNSTUCK MINISTRY - Final
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  • UNSTUCK MINISTRY

    Intake Form

  • PERSONAL INFORMATION

  • DOB*
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Marital Status:*
  • Presently living with:*
  • Are you a member of Antioch Outpost?*

  • MARITAL BACKGROUND

  • Date of Marriage
     / /
  • Please Rate Your Marriage:
  • If your current issue involves your spouse, is he/she attending with you?
  • Is your spouse saved?
  • Is this your first marriage?

  • CHILDREN

  • Rows

  • SPIRITUAL/RELIGIOUS BACKGROUND

  • Have you made a commitment to Jesus Christ as Lord and Savior?*
  • Have you received the Baptism of the Holy Spirit?*

  • DESCRIPTION OF YOUR CURRENT ISSUE

  • PARENTS’ BACKGROUND

  • Parents:
  • Saved?
  • Rate your parents' marriage:
  • You lived with:
  • Father deceased?
  • Mother deceased?

  • On a scale of 1 (a little) to 10 (a lot), rate how much each parent loved you. Give examples of how they showed their love.

  • Give three words that characterize your relationship with your father.

  • Give three words that characterize your relationship with your mother.

  • FINAL COMMENTS

  • Have you had any ministry or counseling for this issue? Check all that apply:*
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  • MINISTRY WAIVER

  • I acknowledge that I have chosen to participate in receiving ministry from an Antioch Outpost Lay Minister(s) of my own free will. I acknowledge that the members of the ministry team are not professional counselors, and some members may or may not be ordained or full-time staff at Antioch Outpost and may be lay ministers who volunteer their time and are not paid to minister to me. No guarantees are made or can be made by Antioch Outpost or by lay ministers, that I will receive any particular healing. I waive all rights to claims of liability. I understand that the ministry team will treat my ministry sessions with due confidentiality regarding any statements or written documents concerning me. I waive my expectation of absolute confidentiality, and I acknowledge the ministry team abides by the following guidelines and may: Inform the appropriate person, agency, or civil authority of any harm, or potential harm, that a person may attempt or desire to do to one’s own self or to others. Report any reasonable suspicion of physical or sexual abuse that has been committed or is being perpetrated upon a minor child. Antioch Outpost reserves the right to make such reports, as mandated by law, whether or not they confer with the ministry receiver first. By my signature, I acknowledge I have read and understand all of the above statements and I accept the stated conditions under which the ministry teams operate. Again, I acknowledge I have signed this waiver of my

    If recipient is under age 18, a parent signature is needed.

  • Date
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  • Date
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  • Should be Empty: