Emerge Prayer Intake Form

Date(Required)

Home Phone(Required)

Work Phone

Email(Required)

Name Of Church & Denomination

Occupation

Spouse’s first name

Children's Name(s) and age(s)

I was referred by

Have you been in counseling? If yes, give details.

Briefly describe what brings you to prayer ministry now.

Other crisis situation (Please describe)

Please describe your support system

Have you had any major surgeries, illnesses or accidents? If so, please describe

Have you ever had a severe emotional trauma or physical trauma? If Yes Explain

Are you under a doctor’s care now? For what?

What prescription medication(s) are you currently taking? For what?

How do you spend your leisure time?

Marital status

First Name of spouse

Any previous marriages?

Have you ever been separated or divorced? If so How long?

How many children do you have and what are their ages? Were any adopted?

Have you had any miscarriages or abortions?

Please tell us about your parents; Are they married or divorced? Alive or deceased? Any step-parents? Adopted parents? Were you raised by anyone other than your parents? Briefly explain

Briefly describe your relationship with: Mother, Father, Siblings, Spouse, or significant other

Was there a sense of security and harmony in your home growing up?

How was authority exercised in your home? Which parent was in charge and how did he/she operate?

How was affection shown between your parents and towards you?

Briefly describe any significant details about your birth story

Are you aware of any adultery or incest in your family or that of your grandparents?

Have you or any of your parents, grandparents, or great-grandparents ever been involved in any occultic, cultic or non-Christian religious practices? (e.g. Free Masonry, Palm Reading, Tarot cards, Horoscopes, Medium, Spiritualist, Psychic, etc.)

Any addictions in your family (e.g. alcohol, drugs, gambling, eating disorders)?

Were your parents Christians and did they profess and live their Christianity?

Any history of mental or emotional illness? Suicide?

Are you aware of any generational sin/pattern or habit in your family line?

Have you accepted Jesus Christ as your Lord and Savior? When? Do you attend church? Name of Church? Have you been baptized? Made a profession of faith? How often are you in the Word?

Briefly describe your prayer life? Do you find praying difficult, Explain? Do you have a regular personal time with God? Yes No Have you ever been involved either in reading or in practice with anything “spiritual” that is not Christ-centered? Explain please.

In your own words describe and evaluate your problems?

What steps have you taken to take responsibility for your life and healing journey?

What is your desire in coming for ministry/prayer?

Is there any other information we should know?

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Emerge Prayer Intake Form

Prayer Ministry Intake Form