Freedom Session Registration – Port Hardy Christian Fellowship

Personal Information:

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Email *

Phone

Your Gender *

Male
Female

Your Age? *

Relationship Status: *

Are you content being single?

No
Yes

How long have you been dating

How long have you living common law

How long have you been married?

Number of years.

Is this your ______ Marriage?

1st
2nd
3rd

Separated for how many years?

If less then a year enter 0

Divorced for how many years?

If less then a year enter 0

Widowed how long ago?

If less then a year enter 0

Involvement (Freedom Session/Recovery Programs/Church)

Have you attended Freedom Session in the past? *

No
Yes

When did you take Freedom Session?

Most recent year (2019, 2018-2019)

Did you complete?

Freedom Session
Authentic Living
Graduate

Select all that apply.

Have you attended other recovery programs? *

No
Yes

When did you attend other recovery programs?

Most recent year (2019, 2018-2019)

What recovery programs have you attended and where?

List as many as possible ( i.e.AA, NA, Etc.)

How did you hear about us?

Facebook, Website, Church Service, Friends

Do you attend Port Hardy Christian Fellowship? *

No
Yes

How long have you attended?

x month / x years

Do you attend another Church? *

No
Yes

Which Church and How Long?

My Church x Years

Are you currently under the care of any of the following? *

Counselor
Psychologist
Psychiatrist
No

Select al that apply or no if you are not under the care of any.

Are they in favor of you participating in Freedom Session? *

No
Yes

Are you currently on any medication for any of the following? *

Select al that apply or no if you are not on any medications listed above please select no.

Please explain?

Your honest answers to the following questions will help us place you in the Freedom Session Small Group we feel will be the most helpful to you.

Has anyone suggested you attend Freedom Session? *

No
Yes

Why did they suggest you attend Freedom Session?

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

No
Yes

Have you been told that your expectations are unrealistic? *

No
Yes

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

No
Yes

Do you find yourself believing you are unworthy? *

No
Yes

Are you a “people-pleaser”? *

No
Yes

Does the fear of failure paralyze you into doing nothing? *

No
Yes

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

No
Yes

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

No
Yes

Have you had an abortion? *

No
Yes

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

No
Yes

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

No
Yes

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

No
Yes

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

No
Yes

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

No
Yes

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

No
Yes

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

No
Yes

Have you ever been physically abused by a male? *

No
Yes

Have you ever been physically abused by a female? *

No
Yes

Have you ever been sexually abused by a male? *

No
Yes

Have you ever been sexually abused by a female? *

No
Yes

Do you have gaps in memories from your childhood? *

No
Yes

Do you find yourself avoiding relationships or struggling with intimacy? *

No
Yes

Have you been sexually promiscuous before/outside of marriage? *

No
Yes

Do you smoke? *

No
Yes

How long have you smoked for?

Number of Years.

How many cigarettes or cigars per day:

Do you drink (socially or other)? *

No
Yes

Average Number of Drinks per day?

Average Number of Drinks per week?

Have you ever struggled with chemical dependency? *

No
Yes

How much sobriety do you have?

percentage, time explain.

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

No
Yes

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

No
Yes

Has anyone ever expressed concern about your sexual behavior? *

No
Yes

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

No
Yes

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

No
Yes

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

No
Yes

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

No
Yes

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

No
Yes

Are you significantly over or under weight according to others? *

No
Yes

Have you ever had thoughts of suicide? *

No
Yes

Have you had thoughts of suicide with in the last twelve months? *

No
Yes

Do you feel alone in your problem? *

No
Yes

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

No
Yes

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

No
Yes

Do you avoid intimacy? *

No
Yes

Which type of intimacy do you avoid?

Physical
Emotional
Sexual (If Married)

REGISTRATION / CONSENT / PRIVACY COMMITTMENT *

I hereby give consent, to Port Hardy Christian Fellows to which I submit this form, to use the personal information above 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 submitting 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.

Registration for Freedom Session

Please use this form to register for Freedom Session

Personal Information:

Involvement (Freedom Session/Recovery Programs/Church)

Your honest answers to the following questions will help us place you in the Freedom Session Small Group we feel will be the most helpful to you.