TORSOE Ministry Wellness Application

TORSOE Ministry Wellness Coaching and Retreat Application

Times of Refreshing Simplicity of Eden Ministry Pastor Shelem and Maria Flemons, Biblical Wellness Life Coaches Send Text To: 706-897-8537 Office: 770-713-7388 Website: www.torsoe.org Email: support@torsoe.org
This wellness application is used to assist wellness retreat guests or wellness coaching guests experience wellness the REFRESHING way. If you are filling out this form for someone else, such as a minor or for a handicapped person, please write your name below and indicate your relationship to the person referred to in this form. If you are the legal guardian for the person, please indicate that fact as well. You will then fill out the form, answering the questions as though you are the individual needing health restoration. Type "N/A" if the form is for you.*
Cell Number if you have a mobile phone*

Area CodePhone Number
Full Name*

First NameMiddle NameLast Name
Other Phone Number

Area CodePhone Number
What is the best way to contact you? (check all that apply)*

PhoneCell
Mailing Address*
E-mail Address*
Age*
Weight*
Height*
What is your Gender?*

MaleFemale
Date of Birth*

MonthDayYear
Occupation*
Please choose the most appropriate category that best describes your purpose in filling out this form.*
What is the start date of the retreat you would like to attend if applicable. This does not apply to Wellness Coaching Guests

MonthDayYear
Date
Please tell us how you learned about Times of Refreshing Simplicity of Eden Ministry.

FamilyFriendRadioFlyerTVChurchYou-TubeSocial MediaField SchoolOur WebsiteAdvertisementInternet SearchBroadcast TextAnother WebsiteOther
If you answered "other" to the above question, please tell us how you heard about us.
What are the main diseases that you are suffering from. These are the conditions you wish to recover from.*
Type NA if you have no additional information to add.
Are you Constipated?*

YesNoNot Sure
How often do you have a bowel elimination?*
Describe Your Bowel Eliminations (Hard or Soft) (Long or Short) (Approximate diameter*
How Many Ounces Of Water Do You Drink Everyday?*
Describe Your Urine. (Clear, Slightly Yellow, or Very Yellow)*
List past diseases, conditions, surgeries and / or procedures that you have had within the past five years and include approximate dates. Type N/A if none.*
Please list any prescription drugs that you are taking and the condition for which they are taken. Also give us the dosage such as the milligrams and how many times a day they are taken. Include the number of months or years you have been taking each medicine. Type N/A if none.*
Please list any herbs or supplements you are taking and the condition for which they are taken. Also give the dosage such as the number of capsules, the milligrams (if applicable) and how many times a day they are taken. Include the number of months or years you have been taking each supplement. Type N/A if none.*
Do you have any food allergies? If so, list them below.*
Do you have any other allergies? If so, list them below.*
Do you use tobacco in any form? If so, indicate rather it is smoking or chewing. Also, indicate whether you use electronic cigarettes and for how long. If you have used it in the past, indicate how long you had the habit.*
Do you use or do you have a history of using illegal drugs? If so, please list them and for how long. (within the past five years)*
How often do you consume alcohol?*

DailyWeeklyMonthlyOccasionallyNever
Please indicate your stress level.*

Not stressedMildly stressedModerately stressedHighly stressed
How much exercise do you get?*
What time do you go to bed every night?*
Please check all that apply:*

I drink coffee. (including decaffeinated)I drink teas with caffeine.I eat chocolate.I drink sodas and or soft drinks.I snack between meals.I overeat. (I feel stuffed after meals)I usually drink with meals.I wear short sleeves, short pants or short skirts.I eat at least one of the following: ketchup, mustard, salad dressing and mayonnaise.I eat white flour and white flour products.I eat at least one of the following: eggs, milk or milk products, cheese.I eat at least one of the following: Pork, Beef, Chicken, Fish.I eat lots of desserts, candy or foods with sugar.I chew gumI eat late at night or just before going to bed.I believe I overwork.I watch a lot of television.NONE OF THE ABOVE
Indicate the time of your normal breakfast , And tell us what you typically eat for your first meal. Write "NONE" if you do not eat breakfast.*
Indicate the time of your normal dinner, (or lunch) and tell us what you typically eat for your second meal. If you do not eat dinner, write "NONE."*
Indicate the time of your normal supper (or dinner), and tell us what you typically eat for your third meal. Write "NONE" if you do not eat a third meal.*
DISCLAIMER: Times of Refreshing Simplicity of Eden (TORSOE) Ministry is commanded by God to heal, using His natural methods in cooperation with His power to minister to the sick. These methods include but may not be limited to education, lifestyle change, and simple, biblical, natural remedies used only as God’s instruments of healing. Because God is the only One who can bring about true healing, we do not hold ourselves out as having any titles, innate or acquired abilities, services or products that in any way license enable or equip us to cure or in any way relieve any disease or abnormality. This disclaimer is to serve as notice that we are commanded by God to make use of these remedies as His instruments, but that all healing power comes from God. We are further commanded to make His plan and methods available to others in a way that helps to sustain the ministry. This disclaimer is also to serve as notice that as far as we know, God’s methods and / or instruments of restoration have not been evaluated or approved by any secular governmental agency. They are promulgated, practiced, published, and prepared in obedience to our church tenets. This is your notice that we have been commanded by God to minister in this way, teach others the same and conserve the natural resources of the earth lent to us by our merciful Creator! Please be further advised that any titles that we hold in the area of biblical wellness are religious credentials and do not reflect secular titles secured by state or federal licensure. Therefore, do not seek or accept our help unless you accept the terms of this disclaimer! PLEASE INDICATE WHETHER YOU AGREE OR DISAGREE WITH THE TERMS OF THIS DISCLAIMER.*
Click the up and down arrow above and choose rather or not you accept the terms of this disclaimer
Signature: YOU MUST SIGN WITH YOUR FINGER OR MOUSE*
May we send you our FREE health e-newsletter? You can unsubscribe at any time.*

YES! I can't wait for my first copyNO. Thank You.
Would you like to receive our daily worship and wellness text? You can unsubscribe at any time.*

YES! I can't wait for my first text!NO. Thank You.

Choose one of the options below. If you have previous financial arrangements with TORSOE, leave all boxes blank.

1 Hour Telephone Consultation$100.00

Consultation with written instructions$250.00

Consultation with written instructions, 1 - 2 months of herbs depending on your condition, and continual coaching until you are better or until we have done all that can be done.$500.00

Deposit to attend a wellness retreat$1,000.00

This deposit is to confirm your future attendance in a future wellness retreat.

Total $0.00

Payment Method
Credit	Express

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year
Billing Address
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Please verify that you are human*
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TORSOE Ministry Wellness Coaching and Retreat Application