Spiritual Health: Pre-Session Questionnaire Spiritual Health: Pre-Session Questionnaire Step 1 of 11 9% Please allow at least 10-15 minutes to complete this form. Our Spiritual Health Team takes great honor in caring for you. In order to steward your time well, we invite you to complete this Questionnaire which serves several purposes. First, it helps us to know you better so we can more effectively prepare for the session. Second, it helps us to know specifically what to pray for during the session. Lastly, it gives opportunity to use your time wisely during the session since these things will have already been addressed. Each question is very intentional and has a purpose. We are not asking these questions to just get information. If you prefer not to answer any question, please feel free to skip it. Thank you, and we look forward to serving you. This ministry is currently available only to those 18 and older.Name* First Last Email* Enter Email Confirm Email Phone*Birthdate* MM slash DD slash YYYY Age*Gender*Choose oneMaleFemale Occupation Marital Status*Choose oneSingleMarriedDivorcedSpouse's Name* First Last Emergency Contact Name* First Last Emergency Contact Phone* What is your basic concern, as you see it?*How long have you had this difficulty?*Are there any other problems that grow out of this one?Have you previously sought out help for this concern? Yes No From whom?* Who currently lives in your household?Check all that apply. Spouse Unmarried Partner Children Grandchildren Parents Grandparents Other What ages are the children in your household?* Describe your relationship with those in your household. Describe your childhood family.What is your earliest memory?What is your happiest memory?What is your saddest memory? If you could change anything about yourself, what would it be?Have you had any major losses in your life? Yes No Please describe.Are there any other key events that have influenced your life in some way? Yes No Please describe. Do you have any present medical or mental health diagnoses? Yes No Please describe.Have you ever attempted suicide or been admitted for psychiatric care? Yes No Please describe.Have you ever known anyone who attempted or committed suicide? Yes No Please describe. Do you have any concerns of past or present addictions? Yes No Please describe.Are there any addictive issues in your family history? Yes No Please describe.Do you have a family history of mental illness? Yes No Please describe.Were there ever any adulterous affairs with your parents or grandparents? Yes No Please describe. Have you (or anyone in your household) ever been involved in any other religions or practices (besides Christianity)? Yes No Please describe.Do you spend regular focused time with God? Yes No When and how do you spend regular time with God?What seems to be the biggest barrier to you spending regular time with God?Do you find prayer difficult? Yes No Please explain. Please describe anything additional that you feel would be important for us to know. Consent and Agreement for Services*I acknowledge that the Spiritual Health Team members from Resonance Church have voluntarily agreed to meet and pray for me. I understand that this session is not a professional counseling meeting or relationship and that none of the team members are acting as licensed counselors. I understand that these team members are, to the best of their ability, doing what they can to help me achieve more freedom in my life. I understand that Resonance Church is a non-profit Ohio Corporation that makes no charge for its services. I further state that I have voluntarily sought assistance of my own initiative and that I am under no obligation to accept or reject any of the advice or help that I might receive from the team members of this ministry. I understand that in some instances physical and emotional reactions can result in response to this ministry time. I understand that the Spiritual Health Team is committed to respect my disclosed information. The information, as needed, may be shared with appropriate leaders at Resonance Church, so as to further the total healing process. I agree to hold Resonance Church and its team members free from any and all liability, loss or damage of any kind that may arise as a result of assistance which I have received or from my involvement with the Spiritual Health Team. I have read this disclaimer/release of liability and understand its terms and agreements. My signature signifies my agreement with it and that I am executing it as my free and voluntary act. I agree to the terms outlined.Electronic Signature*By typing my name, I am providing my electronic signature and agree to the terms of the agreement above. PhoneThis field is for validation purposes and should be left unchanged.