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Taking Back Ground Application Form
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Taking Back Ground Application Form
Full Name
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Street Address
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City, State, Zip
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Home Phone
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Cell Phone
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Email
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Gender (original)
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Male
Female
Age
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Marital Status
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Married
Single
Divorced
Separated
Other
How many years have you been a Christian?
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Your Church Name
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Your pastors name and phone number
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Please describe your level of participation
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How long have you been a member of your current church?
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Do you support same sex marriage?
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Yes
No
Please describe the relational or sexual issue you are seeking help for
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How does the problem express itself?
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Do you characterize yourself as having same sex attraction? Please explain.
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Is your problem heterolsexual or homosexual? If homosexual, please describe your sexual activities.
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Do you have any non-sexual compulsive behaviors (i.e. smoking, over eating, spending, etc? Please list.
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Are you currently receiving or have your received counseling in the past? Please describe.
If marraired does your wife know about your problem?
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Yes
No
Are you taking any medications? If so, please list name of medication, the dosage and frequencey of administration
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Will you commit to regular participation in the Freedom Fighters Program?
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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
If you are human, leave this field blank.
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