Name *

First Name

Last Name

Phone *

(###)

###

####

Have you Attended Freedom Session Before? *

Yes

No

Have you Attended aAny Healing Program Before? *

Yes

No

Are you currently on any medication for

None

Depression

Anxiety

Insomnia

Eating Disorder

Emotional / Mental Illness

I hereby give consent, to the organization/church to which I submit this form, to use the personal information above/below for my pastoral care, participation in church related activities and emergency care. I understand that my personal information may be given to pastoral and/or church staff, program leaders, event coordinators and emergency personnel on a need to know basis. My personal information will be securely stored in an appropriate place, and will not be passed on to any third parties without my/our prior consent. By signing and dating this form I indicate that I have read, understand and approve the above and that this information will be stored for a minimum of one (1) year. I further understand that neither Freedom Session Resources nor Freedom Session International Ministries has any privilege to this information or responsibility for it.

Yes

No