ONLINE COUNSELLING/DELIVERANCE
FIRST NAME
LAST NAME
EMAIL
TELEPHONE
COUNTRY
Please select any of the items below that apply and feel free to add any others at the bottom under "Any other concerns or issues."
You can do Multiple Selection by holding down on 'ctrl' button on your computer keyboard.
Any other concerns or issues:
Please look back over the concerns you have checked off and choose the one that you most want help with counseling, prayer therapy or deliverance. Write the numer(s) in the box opposite:
PRIVACY DECLARATION
This is a strictly confidential patient medical record /concerns. Law expressly prohibits redisclosure or transfer.
Checklist of Concerns