Healing Rooms Form

Name

First Name

Last Name

Address

City

State

Zip Code

Phone

(###)

###

####

Age

Born Again?

Yes

Church Name / Affiliation:

Married?

If Yes, Name of spouse:

Children?

If Yes, How many children?

Are you currently under the care of the doctor, counselor or other health care professional?

If yes, check all that apply:

Medical Doctor

Licensed Counselor

Other...

How did you hear about our Healing Rooms?

I am needing healing for:

Do you remember when the condition that you are seeking prayer for began? If so, When?

Were there any traumatic events happening at or during the time your condition began? (If so, please provide a brief description)