Healing Prayer Ministry Intake Form

Name

This address will receive a confirmation email

Phone

Address

Sex

Male Female

Date of Birth

Ranking
Please rank the seriousness of your areas of concern on a scale of 1 to 5. If the situation or condition you are suffering is extreme, your rating would be toward a 5 on the scale. If it is a minor concern, your rating would be toward 1 on the scale. Please be direct and rate how you are doing in each of the areas.

Spiritual

Physical

Relational/Social

Emotional

Mental

Sexual

Why are you seeking Healing Prayer? What is a description of your current issue?

Marital Status

Single Married Divorced Widowed Separated Remarried

Name of Spouse (if applicable)

If you have had previous marriages, please list how many.

Name and ages of children (if applicable), please include biological, step, adopted, miscarriages, deceased, aborted.

Spiritual/Religious Background

Have you made a commitment to Jesus Christ as your Lord and Savior

Yes No

If you answered YES, how old were you?

Have you received the Baptism of the Holy Spirit?

Yes No

If you answered YES, when did it happen?

Do you attend church?

Yes No

If YES, where do you attend church?

Were you ever hurt by the people in the church? Yes No

Please list all previous church affiliations:

Do you have a loving group of believers who can support you in prayer?

Yes No

Do you participate in a small group, home group, or life group?

Yes No

How did you hear about the Franklin Vineyard Healing Prayer Ministry?

Have you or your family had any of the following ailments?

Female Problems

Glandular Problems

Thyroid

Heart Disease

Diabetes

Asthma/Skin Issues

Autoimmune

Cancer

Please list what type of Cancer you or your family has had or have below:

Other

If you answered OTHER, please list those ailments below:

Are you presently taking any kind of medication for physical reasons? Yes No

Difficult Life Experiences

Physical Abuse

Emotional Abuse (verbal, manipulation, co-dependency, favoritism)

Sexual Abuse (rape, molestation, incest, unwanted touching, trafficked, prostitution)

Violence (beating, stabbing, gunshot, torture, murder, suicide, trauma, kidnapping)

Incarceration/Jail

Addiction (alcohol, drugs, marijuana, pain medication, pornography, sex, gambling)

Abortion

Relational Losses (sudden death, estrangement, abandonment, adoption)

Marital/Relationship Problems (separation, divorce, adultery, cheating)

Mental Health Problems

Cancer, Serious Health and Lengthy Hospitalizations

New Age Spirituality, Occult, and Idolatry (fortune telling, divination, voodoo, crystals, hex, santeria, blood sacrifice, tarot cards, witchcraft, sorcery, spells, incantations, yoga, shamanism, ancestor worship, freemasonry)

Next Steps

The next step is to schedule your sessions with a prayer team.

We ask that you plan for at least two sessions at the same day and time each week. You may need less or more time. At the end of each session, you and the team will evaluate the need for another session.

When is the best time and day(s) for you to come for sessions?

Please let us know if there is anything else we need to know about your schedule.

Healing Prayer Ministry Intake Form

Description

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