Name *

First Name

Last Name

Phone *

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Do you consider yourself a follower of Yeshua? *

Yes

No

Have you ever tried any of the following activities, seriously or in fun? (please check all that apply) *

Ouija Boards

Tea Leaves Levitation

Fortune Telling

Tarot Cards

Automatic Writing

Reiki Healing

Wicca Involvement

Horoscopes

Astrology

Eastern Meditation

Acupuncture or Acupressure

None of the above

Have you ever visited, attended or participated in: *

A medium

A spiritist

A Temple or Worship Center of a False Religion (Hindu, Buddhist, etc)

A Temple or Worship Center of a Secret Society (Freemasons, Shriners, etc)

A Secret Society (Freemasons, DeMolay, Eastern Star, Rainbow Girls, Shriners)

A séance

A palm reading

A New Age store

A New Age festival

A fortune teller

Yoga classes

Martial Arts training

A religious cult

A satanic cult

A satanic ritual

A practice of witchcraft of any kind

None of the above

Have you engaged in illegal drug use? *

Yes

No

Are you addicted to any substances or habits? *

Yes

No

Have you had any traumatic experiences? (Death in family, divorce, discharge from work, divorce of parents, auto accident, fire, near-death experience, rape, death of a child, extreme humiliation, extremely unfair treatment, etc.) *

Yes

No

Do you deal with any regular or recurring fears? *

Yes

No

Do you deal with any regular or recurring illnesses? *

Yes

No

Has anyone in your life (especially loved ones or those in authority over you) spoken harsh words against you? *

Yes

No

Have you spoken harsh words against others in your life? *

Yes

No

A curse can come to a person through no fault of their own. Those who engage in prayer ministry have identified seven possible indicators of a curse on a person’s life or in a family line (similar to Deuteronomy 28): 1. Mental and/or emotional breakdown 2. Repeated or chronic sicknesses (especially if hereditary) 3. Infertility, a tendency to miscarry or related female problems 4. Breakdown of marriage and family alienation 5. Continuing financial insufficiency 6. Being accident-prone 7. A history of suicides and unnatural or untimely deaths (Derek Prince, Blessing or Curse, 53). Do you recognize any of these in your life or in the life of your family? *

Yes

No

By filling out the form above and by agreeing to participate in a prayer session, I acknowledge that I have read and understand the Waive of Liability and Waiver of Confidentiality and that I accept the stated conditions and limits of confidentiality.

Ohev Yisrael Messianic Jewish Congregation Waiver of Liability and Confidentiality Referral I understand that if the Personal Prayer Ministry Team Member is not equipped or able to minister to my need or if I need longer term ministry, they may refer me to appropriate help. Waiver of Liability I understand that I will be seeing Personal Prayer Ministry Team Member(s) who will be able to listen, support, encourage, pray, and minister to me to help me overcome my problem(s) and to grow in my life as a follower of Yeshua. I accept that they may not be a licensed or professional rabbi/pastor or counselor. Waive of Confidentiality I am aware that all statements that I shall make to the Personal Prayer Ministry Team members(s) are of a confidential nature, including all written information, and that legally and ethically these may not be disclosed without my written consent. However, I waive my right to ‘complete’ confidentiality in the following situations: • I acknowledge that Rabbis, Counselors, Congregation, or Personal Prayer Team Members or any other persons involved in working with adults and children in a helping setting at Ohev Yisrael Messianic Jewish Congregation are either encouraged or required by law to disclose to the appropriate person, a gency, or civil authority any harm, or potential harm, that a person my attempt or desire to do to one’s self or to others. • I acknowledge that Rabbis, Counselors, Congregation, or Personal Prayer Team Members at Ohev Yisrael Messianic Jewish Congregation are also required to report any reasonable suspicion of physical or sexual abuse that has been done or that is being done to a minor child or vulnerable adult. • I accept that all Rabbis, Counselors, Congregation, or Personal Prayer Team Members at Ohev Yisrael Messianic Jewish Congregation with me first. By filling out the form above and by agreeing to participate in a prayer session, I acknowledge that I have read and understand the Waive of Liability and Waiver of Confidentiality and that I accept the stated conditions and limits of confidentiality. I have read and understand the waiver above and I accept the stated conditions and limits of confidentiality:

Yes, I have read and understand the waiver above and I accept the stated conditions and limits of confidentiality

No, I refuse to consent to the waiver above