Healing Retreat Application Form

Name

First Last

Email

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Cell Phone

Personal Detail

Gender

Marital Status

Date of Birth

Home church (if applicable)

Please describe your Faith journey/story in a few words. If you consider yourself a Christian, please tell us briefly how and when you became one.

Which area or areas below do you feel you need prayer in? Please give some brief details.

Physical healing
Mental stress
Emotional hurt
Phobias/Fears
Addictions
Other

Are you experiencing difficulty with any of the areas below? If so, please give some brief details.

Marriage partner
Parents
Children
God
Church
Authority figures
Other

Have you received, or are you currently receiving, any of the following types of help concerning your present needs? If so, please provide some brief details.

Medical
Psychiatric
Counseling
Other

Have you received, or are you currently receiving, ministry from your church? If so, please provide some brief details.

Have you received, or are you currently receiving, help from any other healing-related organization? If so, please provide some brief details.

Have you or your family (i.e. parents, grandparents) been involved in any spiritual-related activity, organization or belief system that isn't Christian-based? If so, please provide some brief details.

Healing Retreats

If applying for a healing retreat please tell us which one you are applying for. (Available healing retreat dates are given on our web-site.)

Personal Ministry Appointments

If applying for a Personal Ministry Appointment please indicate which item below applies to you.

A. I could be available almost any time on a weekday given a resonable amount of notice.
B. I could generally be available mornings on certain days of the week.
C. I could generally be available afternoons on certain days of the week.
D. I could generally be available evenings on certain days of the week.
E. There are only a few times I could come in the next 2 months.
F. Other

If items B through E apply, please also indicate the day(s) or time(s) that you could be available.

Ministry Needs/Requests

If applying for a Personal Ministry Appointment please indicate which item below applies to you.

A. I feel a strong need to have only persons of my gender on my ministry team
B. Other special needs/requests

If you select one of the options, please provide brief details.

Special Needs

If any of the following apply to you please provide brief details below.

None
Wheelchair
Unable to climb stairs
Hearing difficulties
Poor sight
Special diet
Medication
Other

Please give any other information which you think might be helpful to us in knowing how we can best help you.

How did you hear about us?

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Phone

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