Freedom & Prayer | Deliverance Intake Form

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Personal Information
Date*
MM slash DD slash YYYY
Your Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Email*
Phone*
Best time to call?*
Biological Gender*
- Male
- Female
Age*
Are you currently employed?*
- yes
- no
Employers name*
Highest education level attained*
Do you attend Northwoods?*
- Peoria
- Canton
- No
Do you attend church? If so, where?*

Mental Strongholds
Are there areas of emotional immaturity that you are aware of (fear of commitment, unable to resolve relational conflict)? Please explain.*
If this does not apply to you, please write "not applicable."
Can you identify any destructive or negative patterns of thinking? Please explain.*
If this does not apply to you, please write "not applicable."
Are there any patterns of thinking that often lead to negative behavior? Please explain.*
If this does not apply to you, please write "not applicable."
Are you affected by any cultural or geographical strongholds (patterns of thinking), such as racial prejudice, victim of poverty, religion, pride, intellectualism, etc.? Please explain.*
If this does not apply to you, please write "not applicable."
Are you given to uncontrollable fantasizing, daydreaming, or losing track of time? Please explain.*
If this does not apply to you, please write "not applicable."

Family History
Describe your relationship with the following people.*
Spouse, Children, Father, Mother, Siblings, Grandparents, Step-Parent, Step-Siblings, Others
Parents
Were you a planned pregnancy?*
- yes
- no
- I don't know
Were you conceived out of wedlock?*
- yes
- no
- I don't know
Were you conceived as a result of a rape?*
- yes
- no
- I don't know
Were you born after a traumatic pregnancy? (I.E. "We shouldn't be having this child.")*
- yes
- no
- I don't know
Were you adopted?*
- yes
- no
- I don't know
If yes, what age?*
If yes, do you know your biological parents?*
- yes
- no
Are your parents still living?*
- yes
- no
- I don't know
If no, how old were you when they died?*
Are your parents Christians?
- yes
- no
- I don't know
Are your parents presently married or divorced?*
- Married
- Divorced
- I don't know
If divorced, please explain why and when.*
Who provided discipline in your home, and how was it handled?*
How was affection demonstrated by different members in your home?*
How would you describe your family's financial situation when you were a child?*
Please check which description most accurately describes your parents.
Father*
- Passive
- Strong
- Provider
- Dominant
- Absent
- Manipulative
- Other
Provide any additional explanation.*
Mother*
- Passive
- Strong
- Provider
- Dominant
- Absent
- Manipulative
- Other
Provide any additional explanation.*
In whose homes were you raised? (Check all that apply)*
- Both biological parent's home
- Father's home
- Mother's home
- Grandparent's home
- Other relative's home
- Orphanage
- Foster home(s)
- Adoptive parent's home
- Friend's home
Was there a sense of security in your home during the first five years?*
- yes
- no
If no, please explain.*
Was there a sense of security in your home from age 6–12?*
- yes
- no
If no, please explain.*
Were you raised in a Christian home?*
- yes
- no
Was your upbringing in an alcoholic or drug-dominated home?*
- yes
- no
Do you have brothers or sisters?*
- yes
- no
If yes, please list their name, age, and relationship to you (brother/ sister/ full/ half/ step)*
Name Age Relationship
Immediate Family
What is your current marital status?*
- Single
- Married
- Divorced
- Separated
- Widowed
If married, how long?*
Spouse's Name*
Do you have children?*
- yes
- no
Please list them in birth order*
Name Age Sex
How many times have you been married?*
Briefly describe each marriage relationship.*
Have you ever been divorced?*
- Yes
- No
How many times?*
Explain why you divorced.*
How many times has your spouse been married?*

Additional Relevant Information
Are there any other problems you feel this intake form has not addressed?
Is there any additional information that you feel our team needs to know?
If you have encountered difficulty or confusion in filling out this questionnaire, or in any way have concern about your experience, please contact Northwoods and ask for the Life Help Department.
Phone: (309)-243-1550 OR Email: prayer@northwoods.church

Voluntary Release, Assumption of Risk, and Indemnity Agreement*
In consideration for being permitted to participate in voluntary prayer ministry, herein referred to as the “Prayer Ministry,” the undersigned, herein referred to as the “Releasor,” agrees as follows:

RELEASE, WAIVER, DISCHARGE AND COVENANT NOT TO SUE

Releasor and releasor’s personal representatives, assigns, insurer, heirs, executors, administrators, spouse and next of kin, hereby releases, waives, discharges and covenants not to sue Northwoods Community Church of Peoria, Illinois and its directors, officers, elders, pastors, deacons, ministry team members, employees, agents and volunteers, as well as its successors, affiliates, and subsidiaries, all herein referred to as the “Releasees,” from any and all liability to Releasor, and to

Releasor’s personal representatives, assigns, insurers, heirs, executors, administrators, spouses and next of kin for any and all loss, damage, or cost on account of injury to the person or property or resulting in the death of Releasor, whether caused by the negligence of Releasees or otherwise while Releasor is participating in the Prayer Ministry and any other activities in connection with the Prayer Ministry.

ASSUMPTION OF RISK

Releasor understands, is aware of, and assumes all risks inherent in participating in the prayer ministry. These risks include, but are not limited to, physical and emotional responses and reactions as a result of this Prayer Ministry.

INDEMNITY

Releasor agrees to indemnify Releasees from any liability, loss, damage or cost Releasees may incur due to the participation by Releasor in the prayer ministry whether caused by the negligence of Releasees or otherwise. Releasor assumes full responsibility for and risk of bodily injury, death or property damage due to negligence of Releasees or otherwise while participating in the Prayer Ministry.

Releasor expressly agrees that this Voluntary Release, Assumption of Risk and Indemnity Agreement, herein referred to as “Agreement,” is intended to be as broad and inclusive as permitted by the laws of the State of Illinois and that, if any portion of this Agreement is held invalid, it is agreed that a balance, notwithstanding, continue in full legal force and effect. This Agreement, along with the Ministry Agreement contains the entire agreement between the parties in regard to the Prayer Ministry.
- I have carefully read this agreement. I understand, and it is a release of all claims, including the negligence of Releases. I have been given an opportunity to review this agreement with an attorney of my choosing. I understand that I assume all risks inherent in the Prayer Ministry set forth in this Agreement. I understand that I am indemnifying the Releasees. I voluntarily sign my name evidencing my understanding and acceptance of the provisions of this Agreement.
Ministry Agreement*
Consideration for being permitted to participate in voluntary pastoral and religious counseling, herein referred to as “Counseling”, and prayer ministry, herein referred to as “Prayer Ministry”, the undersigned, herein referred to as “Counselee”, agrees as follows:

1. This is a church-based ministry of Northwoods Community Church providing Counseling and Prayer Ministry in individual and group settings. Our Counseling is done by pastoral staff and lay-ministers, herein referred to as “Counselors.” These individuals are not acting as licensed professional counselors, social workers, or psychologists because they perform religious counseling and not secular or psychological counseling. If it becomes apparent that secular or psychological counseling may better address the Counselee’s needs, the Counselor will immediately initiate a referral to a licensed professional counselor, social worker, or psychologist. If you believe that you have questions which would benefit from the assistance of a psychotherapist or other mental health professional, it is ultimately up to you to decide whether to pursue mental health services and, if so, to select the provider whom you wish to see.

2. Under all circumstances, sexual contact between a Counselor and Counselee is prohibited. If any Counselor suggests or attempts sexual advances, the Counselee shall terminate the session immediately and report the incident to the Executive Senior Pastor, or any other Elder not involved in the counseling.

3. Under normal circumstances, your Counselor will use their good faith efforts to keep your discussions in confidence. However, you should be aware there are some situations in which your Counselor may be required by law to report information to the proper authorities without your permission or knowledge. These situations include but may not be limited to: a Counselee’s intent of harm to self or others, involvement in a felony, suicidal intentions, and/or reasonable evidence of child or elder abuse or neglect. Your Counselor may also disclose information in response to a subpoena issued by a court of law. Additionally, if you occupy a leadership or ministry position, your Counselor may also disclose information to the person in authority over you, in the event he or she deems it relevant to your fitness or ability to fulfill your position.

4. Officially recognized church staff and lay-personnel may also have limited access to your pastoral file. Any other person seeking access to your pastoral file may do so only with your written permission. However, Northwoods Community Church cannot guarantee complete confidentiality with regard to the information received from you. Because our guidance is spiritual as opposed to mental health in nature, it is also important for you to understand that the law may place limits on the confidentiality of the information that you share with us. We do not have the broad confidentiality privileges of a psychotherapist or other licensed mental health professional, so it is entirely possible that our records could be subpoenaed and/or that we could be required to testify in judicial proceedings involving you or your family members. If you have concerns about the confidentiality of any information you intend to share with Northwoods, you should consult an attorney before revealing the information to us. Please rest assured that we strongly prefer not to disclose your personal information and that, within the limits of the law, we will make every effort to protect your privacy.

5. Northwoods Community Church requires that parent(s) must be actively involved in any Counseling and/or Prayer Ministry that is extended to a minor child as determined by the Counselor. At the discretion of the Counselor, parent(s) will be required to make themselves accountable for active participation in Counseling and/or Prayer Ministry offered by Northwoods Community Church.

6. Counselees with any concerns or questions about this agreement agree to raise them with their Counselor at the earliest possible time.

7. This agreement, herein referred to as the “Ministry Agreement”, will govern all relations involved during the term of the counseling process. Should the Counselee participate in Prayer Ministry, the Voluntary Release, Assumption of Risk, and Indemnity Agreement will be incorporated as part of this Ministry Agreement. It is agreed that any disputed or modifications of this Ministry Agreement will be determined directly between the individuals involved. If this Ministry Agreement is not satisfactory, then it is further agreed that disputes and disagreements will be taken to the Northwoods Community Church Board of Elders for mediation. In the event that a satisfactory resolution is not achieved, then it is further agreed that a mutually acceptable third-party mediator will be utilized. All expenses incurred will be the responsibility of the party bringing the dispute.
- I have read the above ministry agreement, understand it, and agree to the terms herein written.
When you click SUBMIT, you will receive an email confirmation with the contents of this form. Please print the email, sign it, and bring it along to your appointment.

Clicking SUBMIT does not guarantee your appointment. Someone from the Life Help team will contact you to schedule your appointment.

Deliverance Intake Form

Personal Information

Ministry Expectations

Spiritual Information

Health Information

Unforgiveness

Permissions to Spiritual Oppression

Behavioral Issues

Hurts and Traumas

Generational Issues

Mental Strongholds

Family History

Parents

Please check which description most accurately describes your parents.

Immediate Family

Family Health History

Additional Relevant Information

If you have encountered difficulty or confusion in filling out this questionnaire, or in any way have concern about your experience, please contact Northwoods and ask for the Life Help Department.

Name	Age	Relationship

Name	Age	Sex