Name *

First Name

Last Name

Today's Date *

MM

DD

YYYY

Phone

(###)

###

####

Birthdate *

MM

DD

YYYY

Is Bethesda your home church? *

Yes

No

In the past 12 months have you had repeated involvement with any of the following: *

Please check all that apply.

Smoking

Use of illegal drugs

Pornography

Gambling

None of the above

Have you ever been involved in the occult, witchcraft, new age or a cult? *

Yes

No

How do you primarily know that God is speaking to you? *

Check all that apply.

Hearing

Seeing

Feeling

Knowing

Dreams/Visions

Other

Are you able to joyfully serve with the Bethesda Inner Healing team and yield to mentoring and correction if necessary *

Yes

No

Have you ever had an inner healing session?

Yes

No

Do you feel you are in a spiritually and emotionally healthy place and feel capable of being a part of this ministry? *

Yes

No