Breakthrough - Inventory

Breakthrough - Inventory

Standard online inventory form based on the referenced PDF. All fields are optional unless the original document clearly marks them required.
Applicant & Contact Information
Last Name
First Name
Spouse
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Saved
Water Baptized
Baptized in the Spirit
Legal Release
I, the undersigned do hereby release Breakthrough Healing Prayer Center and their volunteers or staff from any liability, for any harm or perceived harm resulting from my voluntary receiving of free prayer on this and subsequent visits. I understand that these Healing Rooms are staffed by volunteers representing the body of Christ and reflect many denominations and churches. They are not trained or licensed professionals of counseling, therapy or medical services. I understand that if I am currently taking medication, or operating under the advice of a professional service, I will allow them (my medical doctor, therapist, counselor etc.) to confirm any results of prayer received before altering any prescribed course of action. I understand that this form and all data recorded on it is the sole property of the Breakthrough Healing Prayer Center. All content will be held in confidence for the purpose of ministry to me. Legal Liability Release Signature
Legal Liability Release Date

MonthDayYear
Date
Ministry Background
How did you hear about Breakthrough Healing Prayer Center?
Have you ever received emotional healing, inner healing, or deliverance from other ministries?
Vocation
Marital Status
Have you ever been divorced?
Prayer Request: What 2-3 things would you like to leave at the cross? What 2-3 things would you like to leave with, that you feel you don't have now?
Birth, Family, and Early Life
Were you adopted?
Was your birth planned, and conceived in wedlock?
Were you conceived in violence?
Did your parents want a child of a different gender?
Was your birth traumatic?
Have you been through a process of forgiveness and healing regarding your birth circumstances?
Were your parents born again?
Did you experience poverty, lack, or awareness of family debt?
Did you experience discrimination or prejudice?
Have you experienced healing from childhood wounds related to these issues?
Did you have a sense of security and harmony during the first 12 years of your life?
Parents and Household Dynamics
Relationship with your parents
Was your father
Were you friends with your father?
Were there any special problems with your father?
Have you been through a heartfelt process of forgiveness and healing for your father?
Was your mother
Were there any special problems with your mother?
Have you been through a heartfelt process of forgiveness and healing for your mother?
Was your father the clear head of the household, or was your mother in control of the home?
Was there ever an adulterous affair to your knowledge with your parents or grandparents?
Any incestuous relationships?
If yes to any of the above, have you been through a process of forgiveness and prayed to break these generational patterns?
Are there any addictive problems in your family (alcohol, drugs, tobacco, food, gambling, pornography, etc.)?
If yes, have you prayed to break these generational patterns?
Have you ever done illegal drugs?
If yes, have you repented, renounced, and been freed?
Any cravings that you find difficult to control? If yes, what type of cravings?
What is your ethnic heritage? (If European, from what countries?) If you were born in another country, is there any country of origin trauma attached?
Is there any history of mental illness in your family?
Life Stages
Pre-school years (2–3 adjectives)
K–grade 2 (2–3 adjectives)
3rd–6th grades (2–3 adjectives)
Junior high (2–3 adjectives)
High school (2–3 adjectives)
20s and older (2–3 adjectives)
Trauma, Healing, and Counseling
Have you experienced any serious trauma in your life? If yes, what specific trauma do you want healing from?
If yes, have you been through a process of forgiveness and healing?
Do you feel that the healing has begun but has not yet been completed?
Are you presently under any kind of medication for either physical or psychological reasons?
Are you seeing a counselor or therapist at this time or have you in the past?
Have you ever been hypnotized?
Do you have any sleep issues, including nightmares or night terrors?
Do you experience sexual attacks in your sleep?
Do you have normal cycles of work, rest, and recreation?
Have you ever been sexually molested?
If yes, have you been through a process of forgiveness and healing?
If you have tattoos, do they contain anti-Christian symbolism?
For women: Have you ever had an abortion?
For men: Have you ever coerced a woman into having an abortion?
If yes, have you been through a process of forgiveness and healing?
Do you struggle with
Other struggles
Do you have a regular pattern of BIble reading, devotion, prayer and worship time?
Do you find prayer difficult or blocked?
When attending church or other Christian functions, are you plagued by foul thoughts, jealousies, or other harassments?
Are you under authority of a local church where the Bible is honored, the Holy Spirit is alive and active, and you support it with your time, talent, and treasure?
What fears do you struggle with (if any)?
Other fears
Have you, your parents or grandparents been in any cults?
If so, have you been through a process of renunciation and repentance?
Have you ever done any form of yoga?
If so, have you been through a process of repentance and renunciation?
Have you or have any of your close family members been a member of:
If yes, have you been through a process of generational forgiveness, repentance, and renunciation?
Have you ever had involvement with the following?
Other occult practices
Have you had contact with these?
If so, have you been through a process of repentance and renunciation?
Do you have any of these items in your home?
Other items
If yes for any of the above, are you willing to dispose of them?
Do you struggle with:
Other struggles
PHYSICAL HEALTH: Do you have any physical problems or chronic conditions? What diagnoses or symptoms are you dealing with?
Should be Empty:

Breakthrough - Inventory

Applicant & Contact Information

Legal Release

Ministry Background

Birth, Family, and Early Life

Parents and Household Dynamics

Life Stages

Trauma, Healing, and Counseling