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FREEDOM HILLS
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Confidential Application for Prospective Counselee .

In an emergency, notify:

Marital Status:

Please list the names and ages of all immediate family members. (Including those deceased and year of death)  

Name  |  Age  |  Comments

Questionnaire for an Individual Seeking Help in Understanding Life

*Mark any that describe areas of your life

1. Traumatic Experience
Of What Kind?
2. Emotional Struggles, Conflicts and Conditions
3. Destructive Behavior
4. Immoral Conditions
5. Occult Activity (Past or Present)
Do you ever experience any of the following symptoms?
6. Condemnation - Guilt
7. Drugs (Past or Present)
8. Negative Thoughts
9. Medical Conditions

Briefly Answer the Following Questions 

May we contact your Pastor?

*We will not disclose personal information to your Pastor without your permission. We simply want to work with your leadership, not against them.

Statement of Responsibility for Liability 


I understand that at times Freedom Hills trains counseling interns and during our week of counseling, there is a possibility of interns observing our session from another room. I willingly agree to have a prayer partner/intern, who is being trained, to observe my session. I am aware that interns are required to go through a screening and application process as well as sign a statement of confidentiality.

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I understand that Freedom Hills will not be held responsible for any personal property left, lost, or stolen from the premises during my stay at Freedom Hills.

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I also understand Freedom Hills will not be held responsible for any injury occurring to anyone while in the Freedom Hills program.

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I understand that the staff of Freedom Hills and those associated with them are not professional or licensed counselors, therapists, psychiatrists, medical or psychological practitioners, or if they are licensed in one of these areas, they are not practicing within this area.

 

I understand that the persons counseling me are "pastoral counselors" in the Christian faith, who are helping me assume my responsibilities in finding freedom in Christ.

 

I also understand that my pastoral counselor may need to intervene if he or she suspects that a child (under the age of 18) is currently endangered by abuse or if there is suspected dependent adult abuse or if I am a danger to myself or others.

 

I also understand that I am free to discontinue this pastoral counseling at any time and am at the facility voluntarily.

 

I release from liability the board of trustees and staff of Freedom Hills Ministries from any choice I make or arising from the counseling services or guidance I receive. 

Your application has been submitted. Thanks!

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Testimonials

“Thanks so much for helping us in our marriage. We wanted closeness in our marriage and God has granted us an answer to our prayers. Thanks so much for the part you played in our lives. We are so grateful!”

"Thank you so much for your kindness & welcoming spirits when we were at the ministry! Before heading to FHM, my husband and I had been praying for God to unite us, but neither of us knew how that would happen. It was truly a miracle that God answered that answered that prayer. God has filled us both with His love, and we are now able to pour that out on each other and the people around us. We serve a mighty God who is able to do exceeding abundantly more than we can ask or desire."

“We cannot put into words how much we appreciate you for helping us out. We didn’t realize how much we were missing in our married life. It's like living in a different world. We have a love for each other we can’t put into words. Our children are happier than before. With God’s help we can go on like this, and our love keeps on growing! Thank you for your help!”

"Thank you for fulfilling the ministry of healing & freedom that God has called you to in Jesus. Your blend of Hospitality and allowing us privacy as a couple was just what we needed for the week. Thank you to our counselor for your patient, kind, & insightful work with us as a couple! I feel we are leaving much stronger as a couple!"

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Contact Us

Visits are by appointment only. For additional information or to schedule a visit contact our office by phone or submit the form below. Thanks!

Thanks for submitting!

Application For Prospective Counselee

OR

Completed applications are handled with complete confidentiality. We prayerfully consider each individual request for counseling. Applications will be considered regardless of denomination or church affiliation. We accept applications submitted online, at our location, by mail, fax, or email.     

ADDRESS

5510 TR 419

Sugarcreek, OH 44681

PHONE

P: 330-893-3857

F: 330-893-4044

EMAIL

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