The Branch

Your Name:

Your Email:

Referred By:

Your Church or Fellowship:

Age:

Country of Birth:

Have you ever lived outside the US? No Yes

Have you or are you currently seeing a counselor? No Yes

Do you need physical healing? No Yes

Briefly describe any previous inner healing or deliverance you have received in the past.

What are the reasons you have decided to seek prayer?

Family History

Please list the 1) First Name; 2) Age (or Age when Deceased); 3) Country of Birth (if not the US); and 4) Faith for each family member below:

Mother:

Father:

Stepmother:

Stepfather:

Mothers Mother:

Mothers Father:

Fathers Mother:

Fathers Father:

1st Sister or Brother:

2nd Sister or Brother:

3rd Sister or Brother:

4th Sister or Brother:

5th Sister or Brother:

6th Sister or Brother:

Current Spouse:

Previous Spouse:

Previous Spouse 2:

1st Child:

2nd Child:

3rd Child:

4th Child:

Your History

Were you a planned child? Do not know Yes No

Were you the right sex? Do not know Yes No

Were you adopted? Do not know Yes No

Were you conceived out of wedlock? Do not know Yes No

Do you know of any complications or traumas your mother experienced during pregnancy or birth?

Have you had any miscarriages or abortions? No Yes

If yes, please list your age and "M" or "A." Do the same for all females in your family line.

Did you have any traumatic experiences growing up? If yes, please briefly describe.

Were or are any of the following present in your family… Adultery, Addictions, Abuse (sexual, verbal, emotional, physical or spiritual)? Briefly describe who was involved.

List any current or past physical health problems. Do any of these run in your family and if so, who?

Have you experienced any of the following… Depression, Anxiety, Fear, Inferiority, Insecurity, Feel like a failure, Don’t like yourself? If yes, does this run in your family and who?

Do you currently hold any of these emotional responses toward anyone… Unforgiveness, Resentment, Bitterness, Anger or Hatred? Briefly describe who and why.

Have you or a family member ever committed or attempted suicide? Briefly describe who and why.

List anyone in your family who is Catholic or has a Catholic background?

Have you ever experienced loud thoughts or voices in your head? No Yes

Have you or a family member ever participated in the following… Buddhism, Zen, Christian Science, Hinduism, Islam, Jehovah’s Witnesses, New Age, Religious Science, Scientology, Unitarianism, Freemasonry (Eastern Star, Job’s Daughters, Rainbow Girls, Shriners, Eagles, Elks), Astral Projection, Ouija Board, Clairvoyance, Fortune Telling, Mediums, Tarot Cards Palm-Reading, Astrology, Transcendental Meditation, Spirit Guides, Witchcraft, Dungeons & Dragons, Hypnosis, Seances? Please list any and note if (S)elf or (F)amily member.

Thank you for taking the time to complete this form. Ministers will begin praying for you upon receiving your form and you will be contacted with available dates.