Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Relational Status

Single

Dating

Common Law

Married

Separated

Divorced

Widowed

Gender *

Male

Female

Have you attended Freedom Session before? *

Yes

No

Did you:

Complete Freedom Session

Graduate

Have you attended other recovery programs? *

Yes

No

Do you attend Relate Church? *

Yes

No

Do you attend another church? *

Yes

No

Are you currently under the care of a

Counselor

Psychologist

Psychiatrist

Are you currently on medication for

Depression

Anxiety

Insomnia

Eating Disorder

Other emotional / mental illness

My Journey *

Your honest answers to the following questions will help us place you in the FS Small Group we feel will be the most helpful to you. Please check all boxes that apply. Note: while we do our best to accommodate all who register, we reserve the right to accept or deny registrations based on space, leadership ratios or suitability (in our opinion) that FS will be helpful for you.

Has anyone suggested you attend FS?

Do you feel like you are different than “normal”?

Have you been told that your expectations are unrealistic?

Do you have a strong need for control in your life?

Do you find yourself believing you are unworthy?

Are you a “people-pleaser”?

Does the fear of failure paralyze you into doing nothing?

Do you lie to cover up for someone else’s mistake or drug/alcohol use?

Do you protect others from the natural consequences of their behaviors and/or actions?

Have you had an abortion?

Have you pressured a partner, family member or friend to have an abortion?

Is there one particular event in your life for which you feel intense guilt/shame that you cannot seem to shake and believe you could never be forgiven for?

Are you afraid to upset other people for fear that they will somehow hurt, reject or maybe leave you?

Do you feel like you are personally responsible for other people’s lives, decisions or drug/alcohol use?

Do you make promises or threats that you don’t carry out? (i.e. “If you ever do that again, I’m leaving.”)

Do you/have you experienced feelings of fear/hatred towards the opposite sex?

Do you have trouble believing/receiving God as a loving Father?

Have you ever been physically abused by a male?

Have you ever been physically abused by a female?

Have you ever been sexually abused by a male?

Have you ever been sexually abused by a female?

Do you have gaps in memories from your childhood?

Do you find yourself avoiding relationships or struggling with intimacy?

Have you been sexually promiscuous before/outside of marriage?

Do you smoke?

Do you drink?

Do you drink more than you think you should?

Have you ever struggled with chemical dependency?

Do you find yourself using drugs (prescription and/or illegal), alcohol, or food in secret?

Have you lied to others or made excuses to yourself about your sexual conduct?

Has anyone ever expressed concern about your sexual behavior?

Do you find yourself regularly watching soap operas and or reading fantasy/romance novels?

Do you regularly purchase or view sexually explicit materials? (e.g. magazines, videos or internet)

Have you made efforts to quit a type of sexual behavior and failed?

Does your weight cause you or others to be concerned about your health?

Do you comfort yourself with food when feeling hurt, angry, depressed or bored?

Are you significantly over or under weight according to others?

Have you ever had thoughts of suicide?

If yes, within the last twelve months?

Do you feel alone in your problem?

Do you find yourself trying to change, regulate and control others instead of yourself?

Do you find it hard to trust, especially those in authority?

Do you avoid physical intimacy?

Do you avoid emotional intimacy?

If married, do you avoid sexual intimacy?