The Healing Place - Confidential Assessment /Interview Application

Choose one of the following:*

Name*

First Name Last Name

Student ID#

Email*

Phone*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Personal Information

Are you a born again Christian?*

Date of conversion:*

Are you a member of a church?*

If you are a member of a church, where and how long?*

Do you own a Bible?*

What version of the Bible do you read:*

How often do you attend church?*

What do you believe about healing?*

What do you expect God to do for you through The Healing Place?*

Name of personal physician/clinic*

Physician/clinic Phone*

Medical record available:*

Hospital of choice*

Medical Diagnosis: The condition which brought you to The Healing Place, please describe:*

Sensory assessment – please check all that apply to you*

Can you read?*

Health habits: Do you smoke or use tobacco in any form?*

Do you drink alcohol in any amount?*

Any other information that might be helpful for the staff to know*