Freedom – Set Free

We are pleased to hear that you desire to have a “Freedom Appointment” using the Steps to Freedom in Christ. Please complete this questionnaire as completely and accurately as possible. This information will be shared only with the ministry team that will be assisting during your Freedom Appointment. Any information that you share will be guarded with the strictest confidentiality.

It is not unusual to experience increased spiritual oppression before an appointment. The enemy does not want you to experience fullness of freedom, but God assures you that you have the authority to resist those attacks in Jesus· name (James 4:7; l John 4:4b). To help you understand and fight the battle, we recommend two books, “Victory Over the Darkness” by Dr. Neil T. Anderson and “The Invisible War” by Chip Ingram. Both are excellent books to read to help you better understand spiritual warfare.

We always have at least two ministry volunteers involved in each Freedom Appointment. They have been through special training to meet the requirements for facilitating a Freedom Appointment. If you have questions, please direct them to me at steve.vm@setfreeusa.org.

It will be an honor for us to serve you this way and be part of what Christ is doing and will continue to do in your life. We look forward to meeting with you soon, and we’ll be in prayer for you.

Steve Vander Molen

Domestic Director
Set Free Ministries

Are you a military veteran or first responder?(Required)

Since you are either a military member, veteran, or first responder, please click the link below to go to the Warriors Set Free branch of Set Free.

Click here: Warriors Set Free – Freedom Apt

Please do not continue below.

Click here: Warriors Set Free – Freedom Apt

Please do not continue below.

Name(Required)

First Last

Mailing Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth(Required)

Month

Day

Year

Are you 18 years of age or older?(Required)

Yes

What is your parent or guardian's name and number?

Active Email(Required)

Phone #(Required)

Best Time to Contact You?(Required)

Appointment Availability (In-Person at the office)

Monday

Tuesday

Wednesday

Thursday

Select all that normally work.

Appointment Availability – Virtually Attended

Monday

Tuesday

Wednesday

Thursday

In-person only (not virtually)

Sex(Required)

Are you a Christian?(Required)

Yes

How many years have you been a Christian for?

Do you attend church regularly?(Required)

Yes

Present Church Affiliation & Pastor's Name

Previous Church (if different in the past year)

Complete the following statement. I attend church…

Weekly

Most weeks

Special occasions

I don’t attend

Current job(Required)

What are the areas of growth or issues you would like to work on?(Required)

How strongly do you want help with your problem?(Required)

Very Strongly

Strongly

Moderately

Not my choice to do this

How did you hear about Set Free Ministries/Warriors Set Free??(Required)

Internet/Search Engine

Friend Referral

Social Media

Referral

TV/Radio

Third-Party Review

Other

Who (if anyone) referred you?

PRE-APPOINTMENT SELF-ASSESSMENT

On a scale of 1 to 10, rate yourself in the following areas (1 = No problem, 5 = Moderate problem, 10 = Severe problem):

Depression (Hopelessness)(Required)

Anxiety(Required)

Fear (Irrational)(Required)

Anger (Unhealthy)(Required)

Tormenting thoughts and voices(Required)

Habits and/or behavior over which you have little control(Required)

Self Esteem(Required)

Ability to function in daily activities(Required)

Satisfaction in relationships(Required)

Physical Health(Required)

Bible study and prayer (1 = No problem, 5 = Moderate problem, 10 = Severe problem)(Required)

Reality of God in your life (1 = No problem, 5 = Moderate problem, 10 = Severe problem)(Required)

Personal & Family History

Marital Status (Currently)(Required)

Single

Married

Divorced

Seperated

Widow/Widower

Describe your present marriage

Have any of your (or your spouse's, if married) parents, grandparents, or other relatives, to your knowledge, ever been involved in any occult, cultic, or non-Christian practice?(Required)

Yes

Unknown

Please explain your "Yes" from the previous question.

Religious history of parents and grandparents?

Home life from childhood through high school (moral climate)?

To your knowledge, did either of your parents or grandparents ever have an adulterous affair?(Required)

Yes

Unknown

Please explain the previous answer

Are you aware of any incestuous relationships in the family?(Required)

Yes

Unknown

Please explain the previous answer

As a child, I was

Adopted

In foster care

Assigned guardians

Single parent

Both parents present

History of physical or emotional illness in the family

No – Physical

Yes – Physical

No – Emotional

Yes – Emotional

Please list the names and sex of all of your siblings, and place yourself in birth order.

Are there any unresolved issues that are causing bitterness or resentment between you and any of your siblings and/or parents?

Yes

Are there any addictive problems in your family history (alcohol, drugs, food, gambling, pornography, etc.)?

Yes

Unknown

Is there any history of mental illness?

Yes

Unknown

Is there any history of disease or chronic illness?

Yes

Unknown

Have you or anyone in your family ever attempted (or succeeded) suicide?

Yes

Unknown

How would you describe your personal health?

Excellent

Good

Poor

Are you taking any prescription medication now?

Yes

Unknown

Do you have any addictions or cravings that cause you to find it difficult to control sweets, drugs, alcohol, food in general, etc.?

Yes

Do you struggle with any compulsive behavior patterns?

Yes

Please indicate any of the following thoughts which you have had or are presently struggling with:

Blasphemous

Obsessive

Daydreaming/Fantasy

Sexual fantasy

Lustful

Worry

Inferiority/Inadequacy

Compulsiveness

Hurting yourself

Hurting others

Suicide

Have you ever thought that maybe you were losing touch with reality, and/or do you presently fear that possibility?

Yes

Have you ever experienced any type of trauma?

Physical abuse

Sexual abuse

Emotional abuse

Spiritual abuse

Severe accident

Death of a family member

Abortion

Is there someone in your life with whom you are able to be totally emotionally honest?

Yes

Is there or has there been any physical, emotional or sexual abuse in your family?

Yes

Unknown

Have you ever experienced any anxieties, guilt feelings, or trauma arising out of sexual experience with the opposite sex?

Yes

Have you ever experienced any anxieties, guilt feelings, or trauma arising out of the sexual experience with the same sex?

Yes

Do you have questions or concerns regarding your sexual identity?

Yes

Please write a brief description of how you became a Christian.

Suppose you died tonight and appeared before God in heaven and He was to ask you, "By what right should I allow you into my presence?" How would you answer Him?

Do you have frequent doubts concerning your salvation?

Yes

How would you rate yourself on a scale of intimacy with God? Please indicate one (1=Distant, 5=Very Close).

Do you have regular devotions?

Yes

Please include any other input about your spiritual life and growth that you think may be important.

Divination applies to any activity in which special knowledge or power was sought through psychic or supernatural means other than God. It involves the use of spells, charms or curses to obtain special powers or to control people, events or things. Some examples are below. Check any that you or a close family member may have been involved in, even if it was seemingly innocent or just observing. Write in any others that you may have been involved in but are not listed.

Astral projection (out-of-body experiences)

Bloody Mary

Blood pacts

Body or table lifting (i.e. “light as feather”)

Charms

Crystal use

Fantasy games (like D&D)

Fortune telling

Horoscopes

Hypnotism

Magic (black or white)

Materialization (making things appear/disappear)

Mental suggestion

Ouija board

Palm or psychic readings

Séances

Tarot cards (or other card readings)

A family member has been involved (explain below)

UFO’s

Other (explain below)

Programming of our minds comes from a variety of resources. Check any false religious teachings that you or a close family member have been exposed to or participated in. There are also a number of other negative influences that may not be religious in nature but can influence us at a spiritual level. Check any of the items that have been an influence in your life. Where indicated, write in the name of the group or program. Write in any others that you may be aware of but are not listed.

Alternative medical treatments (involving Crystals, Psychic powers, etc.)

Books or movies about the paranormal

Cults or sects

Eastern mysticism

Horror or slasher films

Lodges/secret organizations (i.e. Masonic Order)

Music that is blasphemous or anti-Christian

New Age teachings

Non-Christian religions(s) (i.e. Buddhism, Hinduism)

Wicca

Other (explain below)

Involvement in satanic ritual, even at the "dabbling" level is serious. Even if you were forced into it against your will, check any type of involvement you may have had or write in any other involvement that is not listed.

Blood letting/offerings

Calling forth demonic spirits

Church of Satan

Curses/spells

Power circles

Ritualistic sacrifice

Satanic ceremonies

Satanic Ritual Abuse

Other (explain below)

Area to explain "Other" from previous three questions.

Have you ever attended a New Age or parapsychology seminar, consulted a medium, Spiritist, or channeler?

Yes

Do you have, or have you ever had, an imaginary friend or spirit guide offering you guidance or companionship?

Yes

Have you ever heard voices in your mind, or had repeating and nagging thoughts, that were foreign to what you believe or feel, like there was a dialogue going on in your head?

Yes

Please add anything you think might be helpful, for us to help you.

GENERAL INFORMATION

I understand that the above information will be used for the confidential purposes of the Freedom Apt and under no circumstance will my information be made public. Additionally, I acknowledge that data collected from Freedom Appointments can be used anonymously for analysis purposes to help us better serve future ministry recipients.(Required)

Yes