Inner Healing Form

Life History Questionnaire

Name *
Address *
Phone *
Date of Birth *
Date of Birth
Personal Background
Highest level completed?
Please explain.
Give name, relationship and age
Brief details.
Spiritual Background
Have you ever been involved in a cult? *
Have you ever been involved in occult activities? *
Check all that apply.
Please explain.
How strongly do you want help for your current problems?
Check all that apply to you: *
Please explain.
Briefly describe.
Current Marriage/sexual partner
Prior Marriage/Sexual partner (list most recent first and any others next)
Your Father
Your Mother
Your Siblings
Childhood Background
Sexual Background
Please explain.
Please explain.
Please read the Legal Liability Release below. Check and sign the appropriate fields if you accept.
I understand that by checking this box I accept the Legal Liability Release. *
*Entering your name in this field constitutes a signature on this form.*
Date *
Parent/Guardian *Entering your name in this field constitutes a signature on this form.*


I, the undersigned do hereby release Nevada House of Prayer and their volunteers or staff from any liability, for any harm or perceived harm resulting from my voluntary receiving of free prayer on this and subsequent visits. I understand that Inner Healing and Healing Room ministries are staffed by volunteers representing the broad body of Christ and reflect many denominations and churches. They are not trained or licensed professionals of counseling, therapy or medical services. I understand that if I am currently taking medication, or operating under the advice of a professional service, I will allow them (my doctor, therapist, counselor etc.) to confirm any results of prayer received before altering any prescribed course of action. I understand that this form and all data recorded on it is the sole property of Nevada House of Prayer. All content will be held in confidence for the sole purpose of ministry in the above.