Name
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First Name
Last Name
Phone Number
Email
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Describe the issue that prompted you to seek ministry at this time.
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EXAMPLES: “I feel insignificant.”” I feel that I will always be abandoned by people that love me”, “I struggle with a lot of grief “ , I struggle with the fear of ______“
How was your life affected by this issue And what are the main emotions that come up when you think about this?
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How do you feel about yourself because of this issue?
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What is the most painful or difficult thing for you about this issue?
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How are others that you love being affected because of this issue?
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EXAMPLES: Husband/family and friends
How is your relationship with God being affected by this issue?
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When did this issue begin / Is it an ongoing issue?
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Is there anyone in your family line that deals with this similar issue?
Please list any negative words spoken to you or about you either currently or in the past that would relate to your current issue.
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Please list any negative beliefs or thoughts you have spoken about yourself that will relate to this issue.
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EXAMPLES: "I will never be able to succeed" or "I will always be abandoned or rejected"
Please list any judgments or vows you made against anyone else that might relate to your current issue.
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EXAMPLE: " I will never be like my father. Or " men/women are untrustworthy and will always let me down."
Did you experience anything Traumatic growing up? If so what was the message you took away from that experience about yourself
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What was the message you took away from that experience about the world around you based on that memory?
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What is the earliest memory when you felt unprotected either by your mom or your dad?
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Please write down the details
