SHALOM HEALING - FAITH CHAPEL MINISTRY APPOINTMENT APPLICATION

Your name *

Email address *

Are you a born again Christian?

Phone number

How long have you been attending Faith Chapel?

Are you currently serving anywhere?

What is time with the Lord currently like?

Are you involved in a Syngery or Small Group?

If you don’t, we highly recommend one. We recommend having someone in your life that you trust to share your prayer experience with, so you have someone to pray with and hold you accountable.

Why would you like to schedule an inner healing session?

Please describe any past church hurt, childhood/adult trauma:

Have you previously had an Inner Healing session, and if so, when was it:

I was...

Raised Christian

Conceived out of wedlock

Foster System

Dad Issues

Mom Issues

Adopted

Unhealthy Family (you can describe below if you’d like to)

Other

Please describe you religious history:

Please describe your ethnicity and family history (include any ungodly generational issues that may be important to know for your session):

Please check off items that you are struggling with or have had in the past that may still have a hold.

Fear...

Anxiety

Dread/Worry

Extreme Fear

Timidity/Shyness

Insecurity/Inferiority

Nightmares/Recurring Terror/Sleep Paralysis

Panic/Anxiety Attacks

Phobias/Paranoia

Post-Traumatic Stress Disorder

Guilt/Shame

Confusion

Loneliness/Los Self-Esteem/Worthlessness

Negative Body Image

Abandonment/Rejection

Emotionally Numb/Unavailable

Trust Issues

Hypersensitivity

Fear of Failure/Fear of the Future

Jealously/Feeling Less Loved by God

Lying

Heaviness/Depression...

Depression/Hopelessness

Inconsolable Sorrow/Grief

Overwhelming Regret

Suicidal

Self-Harm/Cutting

Rejection/Victim Mentality

Loneliness

Humiliation/Self-Hate

Inordinate Excuses

Self-pity/Condemnation

Constant Fatigue/Lethargy/Lack of Focus

Procrastination/Chronic Tardiness

Consistent Quitting/Lack of Organization

Isolation/Withdrawn

Pride...

Lofty looks

Self-righteous/Superiority

Controlling/Overbearing/Domineering

Competitive

Hateful/Hard-heartedness/Mockery

Obsessive Compulsive Disorder

Critical/Judgmental

Prejudice/Racism

Easily Offended

Rudeness/Arrogance/Entitlement

Gossip/Contentious

Stubbornness/Anti-submissiveness/Unteachable

Selfishness/Self-centered

Narcissistic/Intimidation/Manipulation/Possessiveness

Infirmity...

Lingering sickness

Incurable diseases

High blood pressure/Heart disease

Allergies

Digestion/excretion problems

Chronic pain

Accident-prone/Injury-prone

Any sickness that runs in your family

Occult/Divination/Rebellion...

Witchcraft/Sorcery

Rebellious

Divination

Fortune Telling / Palm Reading / Psychic Consultation

Ouija Board / Seances

Astrology/Horoscopes

New Age/The Occult Dark video games (anything with Witchcraft)

Calling on spirits other than God/Satan worship

Demonic Events

Other

Bondage...

Nicotine

Alcohol

Food

Anorexia/Bullimia

Money

Drugs (including pharmaceuticals and marijuana)

Lying

Obsessive Compulsive Disorder

Sex/Pornography/Masturbation

Romance Novels/Fantasizing

Gambling

Media (social, news, etc.) Addictions/Game Addictions

Soul Ties From Sexual Relations

Workaholic

Hoarding

Compulsive Spending

Picking/Ticks/Nail Biting

Unbelief/Doubt

Other

Anti-Christ/Division/Judgement...

Religious / Judgemental/Divisive

Attacking or Denying the Deity of Christ

Religious Spirit (traditions, rules, or works in place of a relationship with Christ)

Persecuting or Harassing Christians

Controlling Behavior/Opposing the Word of God

Pharisee Spirit/Mocking the work of the Holy Spirit, healings, miracles, etc.

Atheism

Obsession with politics with being “right”

Sexual/Perversion/Harlotry...

Adultery/Infidelity

Fornication

Lustful Thoughts

Perversion

Incest

Molested or Raped

Internet/Phone Sex

Orgies/Swinging/Prostitution/Sex industry involvement, etc.

Pornography

Masturbation

Stripping

Same-sex attraction

Sadomasochism/Self-mutilation/Cutting

Unnatural Sexual Appetite or Activity

Other

Lying...

Lies/Deception

Self-deception

Secretiveness

Exaggeration/Flattery/Excessive talking

Religious performance

Hypocrisy

Deceit

Theft

Betrayal

Trauma...

Accidents

Extremely Stressful Experiences

PTSD

Abuse: Physical, Sexual Molestation, Emotional, Verbal.

Assault: Physical, Sexual, Rape, etc.

Bullying/Intimidation

Abuse from authority figures: educational, religious, etc.

Other

Anger/Unforgiveness/Offense

Anger/Rage/Hatred

Offense

Emotionally Abused

Strife

Unforgiveness

Physically Abused

Jealousy

Temper/Cursing

Vengeful

Violence/Abuse/Cruelty

Bitterness/Resentment/Judgmental

Irritability

Anger towards authority/Anger towards God

Self Condemnation

Fighting/Arguing/Bickering/Quarreling

Death...

Murder

Suicidal Thoughts

Self Harm

Suicide Attempts

Abortion

Physical Abuser

Intent to Harm Others

Criminal Activity...

Arrested

Drugs

Incarcerated

Violent Crimes

Stealing or Embezzlement

Sex Crimes

Other

Is there area that is not an option to check but important for us to know?

We are a mandated reporting facility. If there is any harm to a child, an adult or self (suicide plan) that is shared, we are required to report. Please INITIAL BELOW: *

Self Inventory

Please check off items that you are struggling with or have had in the past that may still have a hold.