Revive Church: Additional Healing

Gender *

Address *

Phone number *

Age *

Pick the age bracket you fall into

18-25

26-39

40-59

60+

Referred by/how did you hear about us? *

Marital status *

How many marriages have you been in and reason(s) for ending

Number of children and their ages:

Church you are currently attending and how long:

Have you committed your life to Christ? *

Yes

No

Have you had any Christian counseling and when?

Do you hear from God yourself?

Any other past Inner Healing experiences:

Give dates, places, and whatever information you can.

Are you experiencing any of the following?

Check all that apply.

Depression

Anxiety

Repeated Patterns

Relationship Issues

Insecurity

Offense

Anger

Guilt

Bitterness

Shame

Unforgiveness

Demonic Oppression

Marital Problems

Addictions

Sexual/Porn

Other

What are your biggest presenting issues (struggles) at this time?

Do you believe your issues are emotional, psychological, and/or spiritual?

Do you hear negative voices or experience demonic oppression?

Yes

No

Have you received a Doctor's diagnosis (physical or psychological)?

Yes

No

Are you currently on a prescribed medication or "other" medications?

Yes

No

Do you drink alcohol and/or take drugs? *

Yes

No

Please list any occult practices you may have been involved in:

Do you know of any generational issues/habits/practices in parents, grandparents, or great-grandparents that might be affecting you now?

Have you or others made curses or vows over you, if so what?

How many marriages have you been in and reason(s) for ending? *

What are your greatest joys or hope?

What makes you feel hopeless?

What is the outcome you would like to receive?