Create in Me a Pure Heart Women's At- Home Application

Name *

Street Address *

City, State, Zip code *

Home phone *

Cell Phone *

Email *

Age *

Marital Status *

Married

Single

Divorced

Seperated

Other

How did you hear about us? *

How many years have you been a Christian? *

What is the full name of your Church? *

What is your Pastor's name and telephone number? *

How long have you been a member of your current church? *

Please describe the problem you are seeking help for. *

How does this problem express itself? *

Do you have any other non-sexual compulsive behaviors (i.e. smoking, drugs, alcohol, overeating, spending)? *

Are you currently receiving counseling or have you in the past? Please explain. *

Does your husband know about your struggle? *

Yes

No

N/A

Are you currently taking any prescription medications? If so, please name them, the dosage and current administration. *

Will you commit to regular participation in the Create in Me a Pure Heart women's program? *

Yes

No

Confidentiality Information *

Confidentiality and privilege communication remain rights of all participants according to state law.  However, if an individual intends to take harmful, dangerous, or criminal action against another human being, or against themselves, it is the duty of Free Indeed Ministries leadership to warn appropriate individuals of such intentions.  Suspected acts of child abuse or neglect are required to be reported.  Those warned may include but are not limited to; the person or family of the person who is likely to suffer the results of harmful behavior; the family of the participant who intends to harm himself/herself or someone else, associates and friends  of those threatened or making threats; law enforcement officials.  Before informing anyone who should be warned, Free Indeed Ministries leadership will take all possible steps to first share that intention with the participant.  Every effort will be made to prevent any such breach of confidentiality.

Reply to confidentiality statement *

Yes

No

Any additional information you feel we need to know about.

Create in Me a Pure Heart Women’s At- Home Application