Participant InformationFull Name(Required)Participant Age(Required)Email(Required) Phone(Required)Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Marital Status(Required) Yes NoHow Long Have you Been Married?Do you have children?(Required) Yes NoHow many & what are their ages?QuestionsPlease describe the presenting issue you’d like help with; provide as much detail as possible, including past history and what you are experiencing today.Please describe any thoughts and feelings you struggle with that were not mentioned above.Please describe your relationships with your family of origin:Please describe your efforts to date in searching for healing and recovery (groups, counseling, etc):Have you had any exposure to or been involved with occult activities?Have you ever been molested or abused?Are you on any medications? If so please list the names and diagnosis.Are you having any suicidal thoughts?What is your relationship with the Lord like?When was the last time you had at least one hour of silence with the Lord, alone?What would you say is your greatest need and/or how we could help you the most?CAPTCHADigital Consent(Required) I agree to the privacy policy.Δ
