Freedom Ministry Intake Form

Freedom Ministry Intake Form

Please complete this form to the best of your ability. A Freedom Ministry team member will contact you for next steps once received.

If you are under the age of 18, please have a parent or guardian complete the form.







Note: this is for identifying purposes only. We have many people with the same first and last name so this helps us make sure we are following up appropriately.
































Examples could include: Christianity (various denominations), Islam, Judaism, Buddhism, Hinduism, Sikhism, Mormonism (LDS), Jehovah’s Witnesses, New Age spirituality, Paganism / Wicca, Indigenous/tribal religions (e.g., Native American spirituality, African traditional religions)





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Freedom Ministry Intake Form

Freedom Ministry Intake Form

Liability Waiver
I acknowledge that ministry members and volunteers from the Rock Church San Diego Freedom Ministry have voluntarily agreed to pray for me. The ministry members and/or volunteers are not medical or mental health care professionals and should not be substituted for any care you receive by any medical or mental health professional. We do not perform psychiatric evaluations nor do we prescribe medication.
I understand that these ministry members and volunteers are praying to God the Father, Jesus the Son and the Holy Spirit. The ministry members and volunteers are Holy Spirit filled believers who have been trained in supernatural and divine healing techniques. I understand that Rock Church is a nonprofit California Corporation that makes no charge for its services. I further state that I have voluntarily sought assistance of my own initiative and that I am under no obligation to accept or reject any of the advice or help that I might receive from the ministry members or volunteers. I understand that if I receive ministry from the Rock Church San Diego Freedom Ministry, the team is committed to respect the disclosed information, but not to complete confidentiality. The information, as needed, may be shared with other Rock Church leaders and/or Freedom Ministry team members. I understand that members of any Rock Church San Diego ministries are California state mandated reporters for child and elder abuse. I agree to hold Rock Church and its team members free from all liability, loss or damage of any kind that may arise as a result of assistance, which I have received, or from my involvement with the Rock Church San Diego Freedom Ministry.

Please consult your own physician, mental health provider, or appropriate health care provider, about any recommendations or opinions regarding any medicines. We do not offer any opinions nor recommend that you stop taking any medicines or therapy. Never discontinue treatment or medication without first consulting your physician, clinician or therapist.

I voluntarily agree to participate in the Rock Church San Diego Freedom Ministry prayer session. I understand and assume all risks in participating in Rock Church San Diego Freedom Ministry prayer including, but not limited to, any physical and/or emotional responses or reactions because of prayer.

During the prayer session, I acknowledge that I may receive personal prayer, communion, anointing with oil, inner healing prayer, personal deliverance from demonic spirits, biblical scripture, biblical instruction, and any other Christian practices that could be useful in ministering to me.

Please type name as electronic signature accepting agreement with liability waiver.

By providing your mobile number, you agree to receive text messages from Rock Church. These may be sent via an automated system. Message frequency varies. Reply STOP to opt out. Message & data rates may apply.

Freedom Ministry Intake Form

Freedom Ministry Intake Form

Sins and Strongholds (self-inventory) Checklist
Please check any boxes below that apply either currently or within your past from the provided lists below (this is by no means an exhaustive list)

Fear
Nightmares or reoccurring terror, bed-wetting, timidity, shyness or inferiority, fear of disappointing others, fear of failure, abandonment, authority, loss, rejection, phobias or paranoia, fear of man, dread, worry, anxiety, people-pleasing, fear of future

Error
Deception, cults, false teachers, false prophets, deception, cults, false teachers, false prophets, racism, prejudice, judgmental, irresponsibility, immaturity, inappropriate thinking, confusion, consistently making bad decisions

Infirmity
Lingering disorders in your body, incurable diseases....cancer, diabetes, MS, etc, high blood pressure or heart disease, allergies, digestion/excretion problems, nervous breakdown, chronic pains/sicknesses, accident/injury prone

Divination
Witchcraft, mysticism, channeling, fortune tellers, palm reading, tarot cards, crystal balls, ouija boards, etc, astrology, horoscopes, new age, yoga, the occult, dark video games: Dungeons & Dragons, Magic 8, etc, Calling on spirits other than God, Satan worship

Deaf & Mute
Convulsions, seizures, epilepsy, autism, insanity, OCD, schizophrenia, sleeping disorders, mental illness, bipolar, nervous breakdown, mental instability, deafness, chronic ear pain/ ringing in ears, disease of the eyes and/or ears

Anti-Christ
Attacking/denying the deity of Christ, religious spirit, persecuting or harassment of Christians, controlling, opposing the word of God, Pharisee spirit, atheism, divisive, attempts to replace/devalue Jesus Christ, worship of a "false Jesus," not the Jesus of the Bible

Pride
Pride, lofty looks, self-righteous, controlling, overbearing, domineering, critical, judgmental, prejudice, easily offended, superiority, rudeness, arrogance, entitlement, gossip, stubbornness, unreachable, contentious

Bondage
Nicotine, alcohol, food, money, drugs, various pleasures, sex/pornography, fantasizing, romance novels, social media, cell phone, internet, TV, video games, soul ties from sexual relations or intimidation, workaholic, hoarding

Heaviness
Depression, inconsolable sorrow/grief, broken-hearted, hopelessness, overwhelming regret, suicidal, cutting, rejection, loneliness, humiliation, self-hate, betrayal, victim mentality, inordinate excuses, withdrawn, self-pity, condemnation, shame, guilt, inferiority, postpartum

Harlotry
Sexual sins: seduction, peeping-toms, exhibitionist, adultery, fornication, orgies, swinging, prostitution, etc, pornography, masturbation, lust, rape, incest, violence, sex industry involvement, all idolatry: placing anything or anyone before God

Slumber
Constant fatigue, lethargy, lack of focus, procrastination, chronic tardiness, passionless, chronic apathy, consistent quitting, lack of organization, isolated, withdrawn, satisfied being alone and without

Perversion
All sexual deviations, pedophilia, sexomnia, necrophilia, same-sex attraction, beastiality, sadomasochism, self-mutilation/cutting, unnatural sexual appetite or activity

Jealousy
Feeling less loved by God than others are, not happy when others are blessed and happy, hate, revenge, retaliation, rage, cruelty, mean-spirited, hard-heartedness, mockery, disdains, insecurity, inordinate competition, self-centered

Lying
Lies, deception, self-deception, secretiveness, exaggeration, flattery, excessive talking, religious performance, hypocrisy, manipulation, hiding purchases/activities/relationships, theft, trickery, betrayal, emotional affairs/adultery

Un-Forgiveness
Anger, rage, hatred, murder, temper, cursing, vengeful, violence, abuse, sadism, cruelty, bitterness, judgmental, irritability, anger towards men or women/father or mother, anger towards authority, anger towards God

Trauma
Accidents, extremely stressful experiences, PTSD, abuse: physical, sexual, molestation, emotional, verbal, assault: physical, sexual, rape, etc., bullying, intimidation, abuse from authority figures: educational, religious, etc.

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By providing your mobile number, you agree to receive text messages from Rock Church. These may be sent via an automated system. Message frequency varies. Reply STOP to opt out. Message & data rates may apply.

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