Personal Intake Form

Personal Intake Form

Page 1 of 27

Personal Intake Form
  1. Client's Rights/Informed Consent

    I understand that my personal files are protected as 'CONFIDENTIAL'. As such, identifying specific details of my file may not be disclosed to others without my written consent except as specified by Florida law: 1) as required by subpoena or court order in legal proceedings, 2) when not to do so would potentially result in physical harm to myself or others, 3) to report any disclosure/suspicion of child/elderly neglect or abuse (physical or sexual). Also, I further understand that Christian Healing Ministries, Inc. is a prayer ministry center and not a counseling or therapeutic center.

    I also understand that this ministry uses the services of volunteer prayer ministers who have completed Christian Healing Ministries training program. As such, they are required to consult periodically with the Prayer Ministry Department. I give my permission for my prayer ministers to discuss my prayer needs with the appropriate staff as necessary. If I have any questions concerning my prayer minister's training, experience or qualifications, I have the right to consult with the staff of the Prayer Ministry Department.

    I also understand that this ministry has a limited number of prayer ministers that occasionally must cancel for extenuating circumstances. In the event that my prayer minister must cancel without advanced notice, I agree to either reschedule my appointment or take the next available prayer ministry time.

    I also understand that I am protected by law from any sexual advances or harassment while undergoing ministry. If at any time I feel offended by anything my prayer minister asks, says or does, I acknowledge that it is my responsibility to report it immediately to the staff of the Prayer Ministry Department.

    I understand that because Christian Healing Ministries is a prayer ministry and not a counseling or therapeutic center, Christian Healing Ministries does not routinely keep detailed records and will not provide information for lawyers, or for disability claims or for similar matters.

    The above text is represented in our "Client's Rights/Informed Consent" form. You will be given this form to sign when you arrive for your appointment.
  2. You must agree to this consent by checking the following two boxes before the next button will appear.

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  4. Please note: This form could take from 5 - 30 minutes to complete depending on the details you provide. Please allow up to 30 minutes of uninterrupted time to complete.
  1. First Name(*)
    Please let us know your first name.
  2. Last Name(*)
    Please let us know your last name.
  3. Gender(*)
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  4. Date of Birth(*)
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  5. Address(*)
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  6. City(*)
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  7. State(*)
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  8. Zip / Postal Code(*)
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  9. Home Phn.(*)
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  10. Work Phn.
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  11. Fax
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  12. Your Email(*)
    Please let us know your email address. A valid email address is required for correspondence.
  13. Reason for completing this form?(*)


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  1. Name of Church
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  2. Denomination
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  3. Occupation
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  4. Spouse's First Name
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  5. Do you have children?(*)

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  6. Number of Children
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  7. Children Name(s) & Age(s)
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  1. I was referred by...(*)
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  2. Are you currently under the care of a counselor or psychiatrist? If yes, give details.(*)
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  3. In the past have you been in counseling or received psychiatric care? If yes, give details.(*)
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  4. Briefly describe what brings you to prayer ministry now.(*)
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  1. Rate the degree of severity for issues that pertain to you:
    1 (low) to 5 (high).
  2. Depression
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  3. Marital Problems
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  4. Drug Addictions
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  5. Eating Disorder
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  6. Grief / Loss
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  7. Occult Oppression
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  8. Workaholism
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  9. Unforgiveness / Bitterness
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  1. Rate the degree of severity for issues that pertain to you: 1 (low) to 5 (high).
  2. Chronic Illness
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  3. Homosexuality
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  4. Insomnia
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  5. Alcoholism
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  6. Low Self-Esteem
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  7. Career Decision
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  8. Financial Crisis
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  9. Sexual Identity
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  1. Rate the degree of severity for issues that pertain to you: 1 (low) to 5 (high).
  2. Anger
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  3. Physical Abuse
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  4. Sexual Abuse
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  5. Emotional Abuse
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  6. Relationships
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  7. Loneliness
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  8. Excessive Anxiety / Fear
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  9. Other Crisis (describe briefly)
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  1. Describe your support system.(*)
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  2. Have you had any major surgeries, illnesses or accidents? If so, please describe.(*)
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  3. Have you ever received a full psychological evaluation? If yes, what was the diagnosis and treatment?(*)
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  4. Have you ever attempted to commit suicide or had suicidal thoughts? If so, when? Please explain.(*)
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  1. Spiritual History (Confidential)

         
  2. Religious background in childhood (describe briefly).
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  3. Church Involvement(*)





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  4. Are you a Christian?(*)


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  5. If yes, I consider myself to be...





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  1. The following symptoms may indicate spiritual oppression. Please check any that relate to your experience.









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  2. Please describe any additional factors that led you to suspect spiritual oppression.
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  1. Emotional History (Confidential)

         
  2. Check all that apply.


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  3. Your age when they divorced?
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      (if applicable)
  4. I had no... because of death/divorce/Preoccupation.
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  5. Has anyone close to you committed suicide?
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  6. Your age when they committed suicide? (if applicable)
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      (if applicable)
  7. Where you sexually abused as a child?(*)

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  8. By whom? (if applicable)
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  9. Please describe some of your feelings as a result. (if applicable)
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  1. Were you physically abused as a child?(*)

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  2. By whom? (if applicable)
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  3. Please describe some of your feelings as a result. (if applicable)
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  4. Were you verbally abused as a child?(*)

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  5. By whom? (if applicable)
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  6. Please describe some of your feelings as a result. (if applicable)
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  1. Did you have an alcoholic parent?(*)



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  2. Have you experienced severe trauma?(*)

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      (e.g., house fire, accident, tragedy)
  3. Please explain the trauma.
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  4. Involved in an unhappy marriage?(*)


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  5. Have you felt abandoned by friends? Please describe some of your feelings. (if applicable)(*)
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  6. Do you suffer with low self-esteem? Please describe some of your feelings. (if applicable)(*)
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  1. Have you had or participated in an abortion?(*)

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  2. If so, how many and what was your role?
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  3. Have you been affected by a miscarriage? If so, how many?(*)
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  4. Childhood Memories:

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  5. Do you sometimes lose blocks of time that you cannot account for? If so, how often? Please explain.(*)
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  6. Do you have significant recurring dreams? If so, please describe.(*)
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  1. The Occult Sheet

    One of Satan's favorite weapons against us is occult involvement. Occult involvement means that we seek to gain knowledge or power from a spiritual source other than God.

    WEBSTER'S DEFINITIONS

    Divination : an act of foretelling the future, assuming the help of unseen powers.
    Enchant: to use magic words or charms to place (another) under a spell.
    Witch: one thought to have supernatural powers through a contract with Satan.
    Medium: one supposedly having access to supernatural agencies and knowledge or power derived from them.
    Wizard : a sorcerer, one possessed of magic influence.
    Necromancer: one who claims to reveal the future by communication with the dead.

    GOD'S WORD ON THE OCCULT (Isaiah 47:11-15, Acts 19:18-20, 2 Thess. 2:9-11)

    The Old Testament strictly forbids occult participation in a number of passages. Deuteronomy 18:10-12 reads: "Let no one be found among you who ....practices divination or sorcery, interprets omens, engages in witchcraft, or casts spells, or who is a medium or spiritist (some translations say "wizard") or who consults the dead. Anyone who does these things is detestable to the Lord . . ."

    OCCULT INVOLVEMENT

    We need to remember that all occult involvement brings spiritual confusion. This confusion begins when we seek other spiritual forces besides God. When we open ourselves up to the occult, we violate the first commandment, "You shall have no other God but Me" (Exodus 20:3) and Jesus' commandment, "You shall love the Lord your God with all your heart and with all your soul and with all your mind and with all your strength" (Deuteronomy 6:4-9, Matthew 22:37, Mark 12:30, Luke 10:27).

    Remember, too, that the wrong things we do in innocence and ignorance hurt as well as those things we do deliberately. Satan has set occult traps throughout our world into which he hopes we will fall. God's forgiveness works not only for our sins but also for our errors due to ignorance as well. We must confess and receive forgiveness for our occult involvement , whether it was done on purpose or through ignorance.

    As you read through the following list, ask the Holy Spirit to recall to your mind every involvement you have had. Keep in mind that many of these activities are clearly occult, but the occult nature of some of them may not be as clear. Please mark any and all possible activities, even if there is a question in your mind as to their occult nature. It is not our purpose to teach about each and every one of these activities and why they are considered occult; we are simply trying to give a solid framework for occult renouncement, and we have based our information on the teachings of those who are considered experts in this area.
  1. Please indicate if you have participated in any of the following, whether out of curiosity or in earnest, by selecting yes or no for each question. Please also note if you have renounced your involvement.
  2. Divination: seeking knowledge from forbidden sources.
    (Deuteronomy 18:9-16; Daniel 2:26-28; Isaiah 2:6, 47:1015; Micah 5:12; Acts 16:16)
  3. 1. Have you ever had your fortune told by a fortune-teller or psychic?(*)

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  4. 2. Have you ever had a palm reading, used a crystal ball, consulted tea leaves, etc.?(*)

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  5. 3. Have you ever followed your horoscope or had a chart made to predict your future?(*)

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  6. 4. Have you ever had a tarot card reading - or used cards to predict your future?(*)

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  7. 5. Have you ever played with a Ouija board?(*)

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  8. 6. Have you ever consulted a medium or numerologist?(*)

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  9. 7. Have you ever acted as a channel or medium?(*)

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  10. 8. Have you ever practiced automatic writing?(*)

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  11. 9. Do you own books on astrology, fortune telling, etc., with the intent of using them?(*)

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  12. 10. Have you been a follower of Edgar Cayce, L. Ron Hubbard or any other New Age author?(*)

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  13. If yes to any of the above, have you renounced your involvement in these items?
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  1. Please indicate if you have participated in any of the following, whether out of curiosity or in earnest, by selecting yes or no for each question. Please also note if you have renounced your involvement.
  2. Spiritualism: seeking contact with a forbidden spiritual realm.
    (1 Samuel 28:7-11, 2 Kings 21:6, Isaiah 8:19-22, Leviticus 19:31 and 20:6)

  3. 1. Have you ever attended a seance or spiritualist meeting?(*)

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  4. 2. Have you ever practiced Transcendental Meditation or Yoga connected with its attendant spirituality? (Some just practice the relaxing exercises without subscribing to the philosophy.)(*)

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  5. 3. Have you ever been involved in mind-control, telepathy, ESP or tried hypnotism (without a sufficient medical reason or professional supervisor)?(*)

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  6. 4. Have you ever sought or communicated with apparitions that were not of God?(*)

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  7. 5. Have you ever worshipped in a pagan shrine or temple?(*)

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  8. If yes to any of the above, have you renounced your involvement in these items?
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  1. Please indicate if you have participated in any of the following, whether out of curiosity or in earnest, by selecting yes or no for each question. Please also note if you have renounced your involvement.
  2. Witchcraft: seeking power from forbidden spiritual sources.
    (Galatians 5:19-20; 1 Samuel 15-23, 28:7; 2 Kings 9:22, 23-25; 1 Chronicles 10:13; Isaiah 8:19, 19:3, 29:4; Micah 5:12)

  3. 1. Have you ever been involved in casting spells?(*)

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  4. 2. Have you ever practiced Black Magic or cursed anyone? Have you practiced White Magic? Have you practiced voodoo?(*)

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  5. 3. Have you ever sought healing from a spiritualist (or “curandero”)? Or through charms, amulets or incantations?(*)

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  6. 4. Have you ever used a charm or amulet for protection or good luck?(*)

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  7. 5. Have you studied books on witchcraft, ESP, etc., for personal use?(*)

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  8. 6. Have you ever practiced table-lifting, levitation of objects or of bodies, pendulum-swinging or astral travel?(*)

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  9. If yes to any of the above, have you renounced your involvement in these items?
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  1. Please indicate if you have participated in any of the following, whether out of curiosity or in earnest, by selecting yes or no for each question. Please also note if you have renounced your involvement.
  2. Devil Worship: Satanism.
    (2 Chronicles 11-15; Psalms 106:37; 1 Corinthians 10:22; Revelation 9:20-21, 13:4)

  3. 1. Have you ever attended the meeting of a coven?(*)

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  4. 2. Have you ever belonged to a coven?(*)

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  5. 3. Have you ever attended a Black Mass?(*)

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  6. 4. Have you ever made a promise or a pact with Satan?(*)

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  7. 5. Have you ever made a blood contract with Satan or anyone else?(*)

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  8. 6. Are you a victim of Satanic Ritual Abuse?(*)

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  9. If yes to any of the above, have you renounced your involvement in these items?
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  1. Contact with Objects:
  2. 1. Do you have any object or book in your possession that may bring an evil presence or influence with it? Has someone involved in the occult given you any amulet or object?(*)

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  3. Group Membership:
  4. 1. Have you been a member of the Masons (including Eastern Star, De Molay, Rainbow Girls)?(*)

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  5. 2. Have you ever been or are you currently a member of a violent organization, such as a gang?(*)

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  6. Relationships:
  7. 1. Have you been in an intimate relationship with someone involved in witchcraft, etc.?(*)

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  8. 2. Have you had any sexual partners outside of marriage? If so, you may want to bring this up in your prayer session in order to break ungodly soul ties.(*)

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  9. Generational Bondage:
    (Exodus 34:6-7; Numbers 14:17-19; Deuteronomy 5:8-10; Joshua 22:16-29; Psalms 33:11; Jeremiah 11:10-13; Acts 2:38-39)
  10. 1. Have any of your ancestors been involved in witchcraft, pagan religions, fortune-telling?(*)

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  11. 2. Has anyone in your ancestry been a member of the Masons?(*)

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  12. 3. Has anyone in your family been a member of a violent or racial discriminating gang or organization (such as the KKK)?(*)

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  1. Activities that may lead to demonic oppression:
  2. 1. Have you ever been involved in addictive activities that have led to your being oppressed by a "spirit of sin" (e.g., pornography)?(*)

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  3. 2. Using drugs can leave your mind and spirit unprotected. Have you ever been on a drug trip?(*)

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  4. 3. Have you listened extensively to music that carried with it an evil or satanic influence (e.g., some hard rock groups have dedicated their music to Satan)?(*)

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  5. 4. Have you read literature or watched movies that are evil in nature (including anything related to Harry Potter or Vampires)?(*)

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  6. 5. Have you played any video games of a violent or evil nature (such as Warcraft or Dungeons and Dragons)?(*)

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  7. 6. Do you have a propensity towards superstition or a fascination with evil?(*)

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  1. This section of the form is intended to help you look back in your family history and recognize any negative patterns or problem areas in your family line. Some problems come down vertically (as from grandfather to father) and some horizontally (from aunt to aunt or cousin to cousin). Some of the problems are obvious, others are known only to God. Don’t worry about what you do not know. As you answer the questions below the Holy Spirit will reveal what you need to know and what He reveals He will bring into healing.

    Great traumas may be healed through generational healing prayer without your knowing their exact cause. However, if you find that your problems are not completely resolved after one Holy Communion or healing prayer session, please continue to come back for prayer for the Healing of Generations or individual prayer until you feel free from these bondages. If you were adopted you might not be aware of your biological family’s history, so let Jesus take care of the unknown and concentrate on your adoptive family.

    Remember to ask the Holy Spirit to reveal His Truth to you. He may give you an area that is not listed below but it is essential to put down areas revealed to you in order to break the patterns of generational sin. (There will be a space at the end to add anything not listed.)

    Please check mark any of the following that pertain to you or your family members:
  2. Unusual and/or Violent Deaths or Severe Trauma (mark all that apply).








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  3. Evidence of Occult or Demonic Activity (mark all that apply).






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  1. Habitual Patterns of Sin
    The definition of a soul tie is cleaving together, a relationship whereby two souls are joined or knitted together, and in a sense become as one. In the scripture, “cleave” means to be “knit together,” “bound up,” or to “cleave together. (This definition taken from Breaking Unhealthy Soul-Ties, by Bill & Sue Banks.) To cut a soul tie is extremely important. Even if the relationship was not sexual, there might be a spiritual, emotional or mental tie that is ungodly. If you are enmeshed with a person, a prayer of release or “cut free” from these relationships is necessary. Jesus does not separate us from a person when we have been tied to them in ways that are holy and within God’s plan and will. He only sets us free from the unholy or destructive part or parts of that relationship. This step is an especially important one in marriage or in planning to marry. The result of these prayers allows the marriage bed to include you, your spouse and God.
  2. Check the number of all sexual partners and/or any unhealthy soul ties you have with another.


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  3. Sexual Sins (mark all that apply).









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  4. Other Habitual Sins (mark all that apply).














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  1. Destructive or Abnormal Patterns of Relationships (mark all that apply).










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  2. Diseases and/or Predispositions to Illness (mark all that apply).














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  1. Historical Family Connections (mark all that apply).

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  2. Religious History (mark all non-Judeo/Christian religions in the family or ancestral history).












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  1. In Utero Wounding (mark all that apply).










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  2. Additional notes of things not mentioned above...
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    Add any additional notes here.
  1. When would you like an appointment? Please indicate the best days of the week with morning or afternoon preferences. We will do our best to accommodate your request at the next available opening.
  2. Mondays?
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  3. Wednesdays?
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  4. Thursdays?
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  5. Fridays?
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  7. (*)
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