In-Person Prayer Session Intake Form | Healing Rooms Conejo Valley

Name*

First Last

Email*

Are you seeking healing for Trauma or other condition/issue?*

Trauma
Other condition/issue

What ONE Trauma Healing need may we pray for in this session?*

Briefly explain the circumstances of the trauma you experienced:*

What ONE healing need may we pray for in this session?*

What was happening in your life when this healing need arose?*

Do you know the cause of your healing need?*

Yes
No

Briefly Explain:*

Why do you think you have this issue?*

How long have you been battling this issue?*

Do you have a doctor's diagnosis?

Yes
No

Briefly Explain:

Did another person inflict the trauma on you?*

Yes
No

Did another person cause your condition?*

Yes
No

Have you forgiven this person?*

Yes
No

Did you forgive this person on your own or with the help of another?*

What else would you like us to know as we prepare to pray for you?

Legal Liability Release*

I Agree

By checking "I Agree," I do hereby release Healing Rooms Conejo Valley and their volunteers and staff from any liability and for any harm or perceived harm resulting from my voluntarily receiving prayer ministry on this and all subsequent visits. I understand that Healing Rooms Conejo Valley is staffed by volunteers representing the broad body of Christ who reflect many denominations and local 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 provider that I will allow them (medical doctor, therapist, counselor, etc.) to confirm any healing outcome(s) from prayer ministry I received before altering any prescribed course of action. I acknowledge and agree that if I report any instance of, or plan to, harm myself or others, Healing Rooms Conejo Valley will contact the proper professional(s). I understand that this form and all data recorded electronically in this is the sole property of Healing Rooms Conejo Valley, and all content will be held confidential for the sole purpose of providing Christian healing prayer to me.