Name
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First Name
Last Name
Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
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Email
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Gender
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Age
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What is the issue(s) or biggest pain point that you are currently experiencing? When did it begin? Is this an ongoing issue?
How does this issue impact your spirit, thoughts, or emotions, and/or your life?
Are there any early life experiences that stimulate or trigger this same issue in your spirit, thoughts, or emotions?
Have you ever heard voices in your mind or repeating negative thoughts or phrases? Do these thoughts or phrases carry a weight of emotional burden with them? If so, please explain.
Have you ever had dark, supernatural experiences (i.e. visual - seeing things; physical - feeling a "dark presence," etc.)? If so, please explain.
How is this issue affecting your relationship with God?
What would freedom for your spirit, thoughts, or emotions look and/or feel like? Please be as specific as possible.
Are you willing to own your part of the issue and seek healing?
Do you sense any resistance or hesitancy at the thought of submitting to the healing process? If so, please explain.
Ask God to bring to mind every relationship in which you have a feeling of resentment or bitterness (including God). Please list them here.
Ask God to reveal every person from whom you need forgiveness. Please list them here.
List any condemning words spoken to/about you either currently or in the past (e.g. “You are such a failure” or “You are so stupid.”)
List any condemning or limiting words you have spoken about yourself (e.g. “I will never be able to succeed” or “I’m not good enough.”)
List any judgments or vows that you have made (e.g. “I will never ______” or “Men/Women will always let me down.”)
Below is a list of several life events that could play a significant role in your current situation or issue(s). Please check any/all that apply.
If you checked any of the above significant life events, please give a brief explanation of each.
Please check any/all that are currently present in your life:
How would you describe your current relationship with God?
Have the “negative” or difficult times in your life drawn you closer or pushed you away from God? Please explain.
Check any of the following statements that are currently true in your life:
Were you adopted? Were you raised by someone other than your biological parents? If so, who?
Did your parents want you?
How would you describe the emotional atmosphere of your family of origin?
Please complete the following: "I often felt that my mother _____"
Please complete the following: "I often felt that my father _____"
Do you have any addictions or cravings you wish you could better control? (e.g. food, sweets, drugs, alcohol, shopping, computer / social media, pornography, sex, other). Please explain.
Do you have any addictions in your family and/or in your background? Please explain.
Do you have any history of mental or emotional illness in your family? Please explain.
Are there any recurrent illnesses or diseases that run through your family line? Please explain.
What are some common negative emotions in your family line that maybe in your life and/or impacting your life? (e.g. guilt, shame, fear, anger, rejection, etc.)
What are some common negative behaviors in your family line that maybe in your life and/or impacting your life? (e.g. judgmental, critical, people-pleasing, controlling, etc.)
Check any of the following spiritual practices that you and/or your parents/grandparents have experienced or engaged in:
Feel free to include any explanation or clarification regarding any of the above:
Please read and check each statement as per your agreement:
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