Freedom Prayer Intake Form

Freedom Prayer Intake Form

The purpose of this form is to obtain a picture of your background and present life. Please answer the questions as fully and accurately as possible. They will be reviewed by the Freedom Prayer Coordinator before your appointment and will be shared only with your Prayer Ministry Team. No one else will have access to this information without your approval.
Today's Date

MonthDayYear
Full Name

First NameLast Name
Email
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone Number

Area CodePhone Number
Cell

Area CodePhone Number
Work

Area CodePhone Number
Age
Occupation
Marital Status
Spouse's First Name
How long have you been married?
How would you describe your relationship with your spouse?
Number of Children
Children's Names and Ages
I was referred to Freedom Prayer by:
What brings you to prayer ministry now?
Check the issues that pertain to you.
Other Crisis (briefly describe)
Describe your support system
Spiritual History
Childhood religious background (describe briefly)
Are you a Christian?
Church you currently attend and services/events in which you participate
Describe significant fearful experiences with "evil"
The following symptoms MAY indicate spiritual oppression. Please check any that relate to your experience(s)
Notice: We are obligated to report to relevant State agencies/law enforcement agencies any knowledge that we obtain of imminent or ongoing abuse, danger, or harm to others or yourself.
Release

Freedom Prayer makes no claims of effectiveness, nor do we guarantee results of this prayer session. However, we do believe that God answers prayer and that He heals diseases. By signing below, you are agreeing to hold Wellspring Church, Freedom Prayer, their staff and volunteers harmless for any liability connected to this voluntary prayer session. We recommend that if you are currently taking medications or are operating under the advice of a professional service, that you allow that therapist or doctor, etc. to confirm results of prayer before you alter any prescribed course of action. This form and all data recorded on it are the sole property of Freedom Prayer of Wellspring Church. All content will be held in confidence for the sole purpose of ministry to the above except as indicated in the testimony release below
Your Signature
Parent Signature (for minor receiving prayer)
Today's Date

MonthDayYear
Testimony Release

All sessions are confidential; however, it is helpful to our ministry and to the Body of Christ to be able to report and hear results of healing prayer. Please check the appropriate statement and sign below to allow us to publish orally or in written form, testimony of any healing you receive here today.
Your signature
Today's Date

MonthDayYear
Should be Empty:

Freedom Prayer Intake Form

Spiritual History

Release

Testimony Release