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Enrollment Forms

Pre-Ministry History

The purpose of this questionnaire is to obtain a comprehensive picture of your background. By completing these questions as fully and accurately as you can, you will both save time and allow for positive, meaningful discussion. You are requested to answer these routine questions on your own time, instead of using up your actual counseling time. It is understandable that you might be concerned about what happens to the information about you, because much or all of this information is highly personal. Case records are strictly confidential. No outsider, not even your closest relative or family member or family doctor is permitted to see your case record without your written permission. your text

Section 1: Personal History

Multi-line address
Birthday
Month
Day
Year
Sex
Physical Health
What is Your Highest Level of Education Completed
Have you used drugs other than for medical purposes?
Have you had psychotherapy or counseling?
How strongly do you want healing from your problem?
When you contacted Spring of Hope Ministries, did you already know who you wanted to be your counselor?

Section 2: Marriage Information

Is spouse willing to come for prayer counseling?
Yes
No
Uncertain
Have you ever been separated?
Yes
No
Have either of you filed for divorce?
Yes
No
Date of Marriage
Month
Day
Year
Your ages when married: Husband, then wife
Month
Day
Year
Broken by:
Divorce
Death
Other
Select areas in your marriage that need improvement:

Religious Background (If you do not attend a church, please skip)

Does pastor know you're seeking help?
Does spouse know you're seeking help?

OTHER INFORMATION

Do we have your permission to call your listed home telephone number the day prior to your appointment to remind you of your appointment?

MINISTRY RELEASE AND DISCLAIMER FORM

The purpose of this ministry is for healing of the heart and personal growth. Our team members are trained in using the Word of God and prayer through the power of the Holy Spirit. The results of this approach depend on the willingness of the individual to make wise choices consistent with the teaching of Jesus Christ. Spring of Hope is not a psychological counseling service, nor is it intended to be. I understand that the team members are not licensed psychologists or psychiatrists. While all of our prayer counselors are trained by the Elijah House schools, some of our Prayer Counselors have gone on to continue their education in counseling. I further understand that according to I Corinthians 6:1-8 we should refrain from suing each other and that all healing prayer ministry is being undertaken with the understanding that we will abide by that scriptural premise. All personal information gathered in the course of a ministry session is confidential, and the files are so maintained. I do hereby give permission for the counselor to consult with other members of the counseling team as is needed (names are not used). Supervision of Children: It is our policy that children are not permitted in the waiting room without supervision, nor are they permitted to be in the counseling session unless they are a part of the scheduled appointment. Intern Counselor Training is a part of our commitment to the task of restoration and transformation to individuals and families. As you are participating in the counseling sessions, you may have the opportunity to be working with your counselor and a qualified intern who has been assigned. Please be assured that we always adhere to a strict policy of confidentiality, which includes the interns working with counselees. To comply with legal regulations, any planned or recently attempted suicide, threats, child abuse, elder abuse, dependent person abuse, severe psychosis or severe emotional dysfunction, or criminal behavior will be reported to the proper authorities. I, (person signing) understand the foregoing information concerning this ministry. I have sought this ministry of my own free will and all personal information I reveal is given voluntarily in order to facilitate the team members working with me. This ministry is supported through giving. While we do not charge a fee, we do encourage counselees to give a donation of $60.00- $75.00 to this ministry for each session. Donations for services rendered are not tax deductible. Make checks payable to Spring of Hope Ministries. If you are unable to keep this appointment time, please contact the Spring of Hope office 24 hours prior to appointment time to re-schedule another appointment!

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Date
Month
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