Confidential Assessment /Interview Step 1 of 3 33% Personal InformationName* First Middle Last Student ID# Male Female Age*Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneWork PhoneCell PhoneEmail Address: Faith RelatedAre you a born again Christian?* Yes No Date of ConversionMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Are you a member of a church?* Yes No What church are you a member of?* How long have you been a member?*Please enter a number greater than or equal to 0.How often do you attend church?* Once a week Once a month Occasionally Do you own a Bible?* Yes No Preferred Bible version How often do you read the Word?* Every day Once a week 2 to 3 times a week Once a month 2 to 3 times a month Less than once a month How often do you spend time in prayer?* Every day Once a week 2 to 3 times a week Once a month 2 to 3 times a month Less than once a month What do you believe about healing?*What do you expect God to do for you through the Healing Place?* Medical InformationName of personal physician/clinic* PhoneMedical record available* Yes No Hospital of choice* Medical Diagnosis*Please describe the condition which brought you to The Healing PlaceSensory assessment* Vision Impairment Glasses/contact lenses Blind Hearing impairment Hearing aid Check all that apply.Can you read?* Yes No Do you smoke or use tobacco in any form?* Yes No Do you drink alcohol in any amount?* Yes No Any other information that might be helpful for the staff to know
