Freedom Fighter Wives Issues Program Application

Full Name *

Street Address *

City, State, Zip *

Home Phone *

Cell Phone *

Email *

Age *

Gender *

Male

Female

Marital Status *

Married

Single

Divorced

Separated

Other

How did you hear about us? *

How many years have you been a Christian? *

The full name of your church. *

What is your Pastors name and telephone number? *

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

Please describe the problem you are seeking support for. *

How does the problem express itself? *

Do you have any non-sexual compulsive behaviors (i.e. smoking, over eating, spending, etc? *

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

Are you taking any medications? If so, please name them, the dosage and frequency of administraion *

Will you commit to regular participation in our Wives Issues 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, I agree with above confidentiality statement

No, I do not agree with above confidentiality statement

Any additional information you think we need to know about you