Ministry Intake Form - Warriors Set Free USA

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Freedom Appointment Intake Form

MINISTRY RECIPIENT

Are you a military veteran or first responder? *

Name *

First

Last

Mailing Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Active Email *

Phone # *

Best Time to Contact You? *

Appointment Availability (In-Person at the office)

Monday
Tuesday
Wednesday
Thursday

Select all that normally work.

Appointment Availability - Virtually Attended

Monday
Tuesday
Wednesday
Thursday
In-person only (not virtually)

Date of Birth *

Sex *

Ethnicity

Are you a Christian? *

Yes
No

How many years have you been a Christian for?

Do you attend church regularly? *

Yes
No

Present Church Affiliation & Pastor's Name

Previous Church (if different in the past year)

What are the areas of growth or issues you would like to work on? *

How strongly do you want help with your problem?

Very Strongly
Strongly
Moderately
Not my choice to do this

How did you hear about Set Free Ministries/Warriors Set Free?? *

Internet/Search Engine
Friend Referral
Social Media
Referral
TV/Radio
Third-Party Review
Other

Who (if anyone) referred you?

Marital Status (Currently) *

Describe your present marriage

Describe any previous marriage(s)

Number and ages of children (in any)

PRE-APPOINTMENT SELF-ASSESSMENT

On a scale of 1 to 10, rate yourself in the following areas (1=No problem, 5=Moderate problem, 10=Severe problem):

Depression (Hopelessness) *

1
2
3
4
5
6
7
8
9
10

Anxiety *

1
2
3
4
5
6
7
8
9
10

Fear (Irrational) *

1
2
3
4
5
6
7
8
9
10

Anger (Unhealthy) *

1
2
3
4
5
6
7
8
9
10

Tormenting thoughts and voices *

1
2
3
4
5
6
7
8
9
10

Habits and/or behavior over which you have little control *

1
2
3
4
5
6
7
8
9
10

Self Esteem *

1
2
3
4
5
6
7
8
9
10

Ability to function in daily activities *

1
2
3
4
5
6
7
8
9
10

Satisfaction in relationships *

1
2
3
4
5
6
7
8
9
10

Physical Health *

1
2
3
4
5
6
7
8
9
10

Bible study and prayer *

1
2
3
4
5
6
7
8
9
10

Reality of God in your life *

1
2
3
4
5
6
7
8
9
10

Personal & Family History

Religious history of parents and grandparents?

Home life from childhood through high school

History of physical or emotional illness in the family

No - Physical
Yes - Physical
No - Emotional
Yes - Physical

As a child, I was

Adopted
In foster care
Assigned guardians
Single parent
Both parents present

Check all that apply to you

Eating habits (bulimia, anorexia, compulsive eating)
Addictions (smoking, drugs, alcohol, gambling)
Sleeping related issues (disturbing dreams or nightmares
Abuse (rape or any other sexual, physical, mental, or emotional)
Thought life (obsessive, blasphemous, condemning, and distracting thoughts
Thoughts suicide, guilt and shame
Emotional life (anger, anxiety, depression, bitterness, and fear)
Experienced significant trauma

GENERAL INFORMATION

I understand that the above information will be used for the confidential purposes of the Freedom Apt and under no circumstances will my information (your name and contact info) be connected to me after my appointment. Additionally, I acknowledge that the data collected can be used for analysis to help Set Free Ministries better serve future ministry recipients. *

Yes

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Grand Rapids, MI | Headquarters

700 – 36th Street SE, Ste 108
Grand Rapids, MI 49548

info@warriorssetfree.org
616-726-5400

Georgia Office| Field Office

1022 2nd Ave

Columbus, GA 31091

eric@warriorssetfree.org
706-289-5919

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