Personal Information Form
Tallahassee Healing Prayer Ministries
2760 Capital Circle, NE
Tallahassee, Florida 32308
850.385.9164
~Confidential~
Date __________________
Name_________________________________________________________________________
Birth Date_______________________ Sex: M or F (circle one)
Home Address__________________________________________________________________
Phones: (H)____________________ (W) ____________________ (C) ____________________
E-mail________________________________________________________________________
Occupation/Employer____________________________________________________________
Degree(s): Grades Completed_______ Bachelor’s_______ Master’s________ Other________
I was referred by________________________________________________________________
Have you been in counseling? If yes, give details ______________________________________
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Briefly describe what brings you to Prayer Ministry now________________________________
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Family History
Are you adopted? _____Yes _____No How many children in your childhood family?_____
Where are you in your family line of siblings?_____
Were you raised by anyone other than your natural parents?_____ Explain__________________
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Parents’ Religious Background_____________________________________________________
Personal Information Form Initi al_______
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Marital Status
Married ________ Single _______ Divorced _______ Separated _______ Widowed _______
If married, how many years?_____ If married before, how many times?_____
How many children do you have?_____
What is your current relationship with your children?___________________________________
Personal History
Are you a veteran of any foreign wars?________ If so, which?___________________________
Did your parents wish you were of the opposite sex?_________
How did your parents feel about the news of your conception?____________________________
Have there been any major traumas in your life?_______________________________________
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Is there any large block of time of your life that you do not remember?_______ Explain_______
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Circle any of the following which applied to you during your childhood:
Night terrors Bed wetting Broken home
Incest Nail biting Physical disabilities
Stammering Excessive fear Serious illnesses
Loneliness Molestation Other learning problems
Removed from home Sleep walking Absence of affection
Learning disabilities Unhappy childhood Feelings of rejection
Sexual encounters Frequent illnesses Homelessness
Check the issues that pertain to you. Rate the degree of stress/urgency for applicable areas ---
1 (low) to 5 (high).
___ Depression ___ Chronic illness ___ Low self esteem
___ Marital problem ___ Homosexual ___ Career decision
___ Drug addictions ___ Insomnia ___ Financial crisis
___ Sexual identity issues ___ Eating disorder ___ Alcoholism
___ Grief/loss ___ Occult oppression ___ Workaholism
___ Unforgiveness/bitterness ___ Emotional abuse ___ Loneliness
___ Excessive anxiety/fear ___ Relationships ___ Sexual abuse
___ Anger ___ Physical abuse
Other crisis (describe briefly):_____________________________________________________
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Describe your support system:_____________________________________________________
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Personal Information Form Initi al_______
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Medical History
Have there been medical traumas and hospitalizations?__________________________________
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Are you under a doctor’s care now?_____ For what?___________________________________
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Have you been hospitalized for emotional illness?_______ If yes, why?____________________
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What prescription medications are you currently taking? For what?________________________
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Have you ever used street drugs?______ How long?_______ Are you still using them?_______
Have you had one or more abortions?_____________ How many?______________
Have you had a miscarriage?__________ If yes, how many?____________
Spiritual History
Church Affiliation Present_____________________________ Past______________________
Are you a Christian? ____ Yes ____No ____Uncertain
If yes, I consider myself to be: 1 2 3 4 5 6
Committed Detached
Church involvement: 1 2 3 4 5 6
Very active Detached
Water Baptism____ Date ___________How often do you currently attend church?___________
The following symptoms may indicate spiritual oppression. Please check any that relate to your
experience.
_______ Psychic abilities, clairvoyance, divination, feeling of having “special powers”
_______ Inward perception of a separate personality, name, or voice
_______ Fearful, repetitive night visitations by an evil presence
_______ Difficulty participating in prayer: agitation, nausea, anger, rebellion
_______ Uncontrollable compulsive behaviors: sexual sin, anger, chemical indulgence
_______ Preoccupation with thoughts of death, despair, and hopelessness
_______ Uncontrollable, irrational, paralyzing fear
_______ Unusual, non-typical emotional expressions, e.g., laughter, sadness, crying, anger
_______ Extreme nervousness or negative reactions at the mention of the name of Jesus
Please describe any additional factors that lead you to suspect spiritual oppression
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Emotional History
Check all that apply.
_______ I don’t remember being loved physically as a child (hugs, being held)
_______ My parents divorced when I was a child. I was _____ years old
_______ I had no father growing up because of (circle one): death / divorce / preoccupation
_______ One of my parents/friends committed suicide. I was _____ years old
_______ I was sexually abused as a child. By whom?__________________________________
Please explain some of your feelings:_______________________________________
_______ I had (have) a physical/mental abnormality that brought ridicule from peers
_______ I experienced a severe trauma (e.g., house fire, accident, tragedy). Please explain.
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_______ I was verbally abused as a child. Please describe some of your feelings.
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_______ I was given up as a child for adoption. Please describe some of your feelings.
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_______ I have had an unhappy marriage.
_______ I had an alcoholic parent.
_______ I have felt abandoned by friends.___________________________________________
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_______ I suffer with low self-esteem. Please describe some of your feelings.______________
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_______ I have few clear memories of childhood. Most of my childhood memory is what I’ve
been told.
_______ Do you ever lose blocks of time that you cannot account for?
_______ Do you have dreams about people surround you?
Comments
Please share below any other information that would be helpful for your ministry and wholeness.
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Personal Information Form Initi al_______
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Personal Information Form Initi al_______
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