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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.

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.

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

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. 

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