MINISTRY RECIPIENT Are you a military veteran or first responder? * Select No Yes Date of Birth * MM 1 2 3 4 5 6 7 8 9 10 11 12 DD 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 YYYY 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 Are you 18 years of age or older? * Active Email * Phone # * Best Time to Contact You? * Appointment Availability (In-Person at the office)
Select all that normally work.
Appointment Availability - Virtually Attended Sex * Select Male Female Complete the following statement. I attend church... Current vocation * What are the areas of growth or issues you would like to work on? * How strongly do you want help with your problem? * How did you hear about Set Free Ministries/Warriors Set Free?? * Who (if anyone) referred you? PRE-APPOINTMENT SELF-ASSESSMENT
On a scale of 1 to 10, rate yourself in the following areas (1 = No problem, 5 = Moderate problem, 10 = Severe problem):
Depression (Hopelessness) * Tormenting thoughts and voices * Habits and/or behavior over which you have little control * Ability to function in daily activities * Satisfaction in relationships * Reality of God in your life * Personal & Family History Marital Status (Currently) * Describe your present marriage Have any of your (or your spouse’s, if married) parents, grandparents, or other relatives, to your knowledge, ever been involved in any occult, cultic, or non-Christian practice? * Religious history of parents and grandparents? Home life from childhood through high school (moral climate)? To your knowledge, did either of your parents or grandparents ever have an adulterous affair? * Are you aware of any incestuous relationships in the family? * History of physical or emotional illness in the family Please list the names and sex of all of your siblings, and place yourself in birth order. Are there any unresolved issues that are causing bitterness or resentment between you and any of your siblings and/or parents? Are there any addictive problems in your family history (alcohol, drugs, food, gambling, pornography, etc.)? Is there any history of mental illness? Is there any history of disease or chronic illness? Have you or anyone in your family ever attempted (or succeeded) suicide? How would you describe your personal health? Are you taking any prescription medication now? Do you have any addictions or cravings that cause you to find it difficult to control sweets, drugs, alcohol, food in general, etc.? Do you struggle with any compulsive behavior patterns? Please indicate any of the following thoughts which you have had or are presently struggling with: Have you ever thought that maybe you were losing touch with reality, and/or do you presently fear that possibility? Have you ever experienced any type of trauma? Is there someone in your life with whom you are able to be totally emotionally honest? Is there or has there been any physical, emotional or sexual abuse in your family? Have you ever experienced any anxieties, guilt feelings, or trauma arising out of sexual experience with the opposite sex? Have you ever experienced any anxieties, guilt feelings, or trauma arising out of the sexual experience with the same sex? Do you have questions or concerns regarding your sexual identity? Please write a brief description of how you became a Christian. Suppose you died tonight and appeared before God in heaven and He was to ask you, “By what right should I allow you into my presence?” How would you answer Him? Do you have frequent doubts concerning your salvation? How would you rate yourself on a scale of intimacy with God? Please indicate one (1=Distant, 5=Very Close). Do you have regular devotions? Please include any other input about your spiritual life and growth that you think may be important. Divination applies to any activity in which special knowledge or power was sought through psychic or supernatural means other than God. It involves the use of spells, charms or curses to obtain special powers or to control people, events or things. Some examples are below. Check any that you or a close family member may have been involved in, even if it was seemingly innocent or just observing. Write in any others that you may have been involved in but are not listed. Programming of our minds comes from a variety of resources. Check any false religious teachings that you or a close family member have been exposed to or participated in. There are also a number of other negative influences that may not be religious in nature but can influence us at a spiritual level. Check any of the items that have been an influence in your life. Where indicated, write in the name of the group or program. Write in any others that you may be aware of but are not listed. Involvement in satanic ritual, even at the “dabbling” level is serious. Even if you were forced into it against your will, check any type of involvement you may have had or write in any other involvement that is not listed. Area to explain "Other" from previous three questions. Have you ever attended a New Age or parapsychology seminar, consulted a medium, Spiritist, or channeler? Do you have, or have you ever had, an imaginary friend or spirit guide offering you guidance or companionship? Have you ever heard voices in your mind, or had repeating and nagging thoughts, that were foreign to what you believe or feel, like there was a dialogue going on in your head? Please add anything you think might be helpful, for us to help you. GENERAL INFORMATION I understand that the above information will be used for the confidential purposes of the Freedom Apt and under no circumstance will my information be made public. Additionally, I acknowledge that data collected from Freedom Appointments can be used anonymously for analysis purposes to help us better serve future ministry recipients. *