Ministry Application

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PERSONAL INFORMATION

Your first name: x

Your last name: x

Your street address: x

Your city: x

Canadian Province / U.S. State: x

Your Country: x

Your Postal Code / ZIP: x

Telephone most easily reached: x

e.g., cell, 123-456-7890

Work telephone:

Your Email address: x

Please spell carefully as a receipt will be emailed to you!

Your date of birth: x

e.g., April 18, 1966

Your biological gender: x

Female
Male

Presently living:

Alone
With spouse
With parents
Other

Occupation:

Employed by:

Hours worked per week:

Name of spouse:

His/her date of birth:

e.g., April 18, 1966

Children and ages:

e.g., Mary, 13, John, 12

Your church:

Referred to us by:

Preferred (Eastern time) appointment time(s):

2 p.m.
7 p.m.
Flexible

Only 7 p.m. is available on Mondays. Only 2 p.m. is available on Fridays.

Session type desired: x

Skype
FaceTime
Telephone

Your primary reason for desiring ministry: x

Other issues:

FAMILY BACKGROUND

Describe the atmosphere growing up in your family of origin:

Describe your childhood relationship with your father:

Describe your childhood relationship with your mother:

Did your mother have an easy or difficult pregnancy with you?

Primary caregiver, ages 0 to 6:

How many brothers?

How many sisters?

Your birth order position:

e.g., 3rd out of 5 children

Describe your childhood relationship with your siblings:

ANY SIGNIFICANT PAST EVENTS

At School/College:

Sicknesses:

Injuries:

Hospitalizations:

Physical challenges:

Regrets / Failures:

Deaths:

Emotional / Verbal Abuse:

Physical Abuse:

Sexual Abuse:

Divorces:

Other traumas:

Who have you seen previously for counseling?

Have you had a medical checkup in the past year? x

Are you currently on any medication?

Have you or anyone in your family had drug, alcohol or other addictions?

Is there any occultic or Masonic involvement in your family background?

Have you had any significant events, dreams or emotional upsets lately?

Thank you for taking the time to complete the application.

Our desire is to be as warm and personal as possible. However, those in helping professions need to satisfy the legal requirements of informed consent.

By submitting your application, you are acknowledging that you have read and accept the legal waivers at this link. (This will open in a new window, which you can close when finished, before clicking the "Submit" button below.)

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Personal Prayer Ministry

Changing the world
one person at a time…

Confidential Application For Personal Prayer Ministry

Personal Prayer Ministry

Changing the worldone person at a time…

Confidential Application For Personal Prayer Ministry

Alert!

Changing the world
one person at a time…