Questionnaire
(Confidential)
Please complete the information below and one of our team will be in contact with you to set up an appointment. All information you share is confidential.
ADULT CONSENT STATEMENT
Please read this Consent Statement carefully and answer the two questions at the bottom to continue.
This consult form is for adults 18 years and older. If you are a parent and requesting inner healing for your child, please keep scrolling to complete the “parent and child” consent form.
I understand that my personal files are protected as 'CONFIDENTIAL'. As such, identifying specific details of my file may not be disclosed to others without my written consent except as specified by Florida law: 1) as required by subpoena or court order in legal proceedings, 2) when not to do so would potentially result in physical harm to myself or others, 3) to report any disclosure/suspicion of child/elderly neglect or abuse (physical or sexual). Also, I further understand that Rapha Nation, Inc. is a prayer ministry center and not a counseling or therapeutic center. I also understand that this ministry uses the services of volunteer prayer ministers who have completed Rapha Nation, Inc. training program. As such, they are required to consult periodically with the founder of Rapha Nation, Inc. I give my permission for my prayer ministers to discuss my prayer needs with the appropriate staff as necessary. If I have any questions concerning my prayer minister's training, experience or qualifications, I have the right to consult with the staff of the Rapha Nation, Inc. INNER HEALING QUESTIONNAIRE
After you have completed the above consent statement that best fits your season of life, please ‘open form” below and begin the inner healing questionnaire. It will take you about 20 minutes to complete the form. We highly recommend that you find a quiet place with no distractions and ask God to help answer each question. Please remember that all information shared in this questionnaire is confidential and will not be shared with anyone outside our Rapha Nation Inc. team. We encourage you to be honest as you answer each question carefully.
I also understand that this ministry has a limited number of prayer ministers that occasionally must cancel for extenuating circumstances. In the event that my prayer minister must cancel without advanced notice, I agree to either reschedule my appointment or take the next available prayer ministry time. I also understand that I am protected by law from any sexual advances or harassment while undergoing ministry. If at any time I feel offended by anything my prayer minister asks, says or does, I acknowledge that it is my responsibility to report it immediately to the staff of the Rapha Nation, Inc. I understand that because Rapha Nation, Inc. is a prayer ministry and not a counseling or therapeutic center, Rapha Nation, Inc. does not routinely keep detailed records and will not provide information for lawyers, or for disability claims or for similar matters. For Online Appointments: I understand that I will be using a third-party video conferencing program to communicate during my online prayer appointment. Rapha Nation, Inc. will not record these ministry appointments and will work to keep my time of ministry as secure as possible. With any online platform, there are certain security risks. In the rare case of security breach, I will not hold Rapha Nation, Inc. liable for any security issues pertaining to my online prayer appointment.PARENT AND CHILD CONSENT STATEMENT
Please read this Consent Statement carefully and answer the two questions at the bottom to continue.
This consult form is for parents and children under the age of 18 years old.
I hereby affirm and state that I am the legal parent/guardian for the child listed below. I hereby consent for my child to receive ministry in the areas of Spiritual Counseling, Personal Ministry, and the Ministry of Deliverance that I/he/she has requested, and I release and any volunteer working with Rapha Nation Inc., from any and all liability actual or implied that may occur as a result of this ministry.
I understand that my personal files and my child's personal files are protected as 'CONFIDENTIAL'. As such, identifying specific details of my file may not be disclosed to others without my written consent except as specified by Florida law: 1) as required by subpoena or court order in legal proceedings, 2) when not to do so would potentially result in physical harm to myself or others, 3) to report any disclosure/suspicion of child/elderly neglect or abuse (physical or sexual). Also, I further understand that Rapha Nation, Inc. is a prayer ministry center and not a counseling or therapeutic center. I also understand that this ministry uses the services of volunteer prayer ministers who have completed Rapha Nation, Inc. training program. As such, they are required to consult periodically with the founder of Rapha Nation, Inc. I give my permission for my prayer ministers to discuss my prayer needs and the needs of my child with the appropriate staff as necessary. If I have any questions concerning my prayer minister's training, experience or qualifications, I have the right to consult with the staff of the Rapha Nation, Inc. I also understand that this ministry has a limited number of prayer ministers that occasionally must cancel for extenuating circumstances. In the event that my prayer minister must cancel without advanced notice, I agree to either reschedule my appointment or take the next available prayer ministry time. I also understand that I am protected by law from any sexual advances or harassment while undergoing ministry. If at any time I feel offended by anything my prayer minister asks, says or does, I acknowledge that it is my responsibility to report it immediately to the staff of the Rapha Nation, Inc. I understand that because Rapha Nation, Inc. is a prayer ministry and not a counseling or therapeutic center, Rapha Nation, Inc. does not routinely keep detailed records and will not provide information for lawyers, or for disability claims or for similar matters. For Online Appointments: I understand that I will be using a third-party video conferencing program to communicate during my online prayer appointment. Rapha Nation, Inc. will not record these ministry appointments and will work to keep my time of ministry as secure as possible. With any online platform, there are certain security risks. In the rare case of security breach, I will not hold Rapha Nation, Inc. liable for any security issues pertaining to my online prayer appointment.
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Rapha Nations is a 501C3 non-profit organization, so all of our services are free of charge. Donations are appreciated to help cover the administrative costs of our organization. All gifts are tax deductible.