Account Details

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Password *

Contact Details

Full Name *

Email *

Phone *

Age *
Select …18-2425-3031-3536-4041-4546-5051-5555-6061-6566+

Address *

City *

Province *
Select …AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukonAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Postal Code *

Country *
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Personal Questionnaire

Relationship Status *
Select …SingleCommon LawMarriedSeparatedDivorcedWidowed

Have you attended Freedom Session before? *

Yes
No

When did you attend?

Have you attended any other recovery programs? *

Yes
No

What program and when?

I’m currently under the care of a

Counsellor
Psychologist
Psychiatrist

Are they in favour of your participating in this program?
Yes
No

Are you currently on any medication for: depression, anxiety, insomnia, eating disorders or any other emotional or mental health disorders? *

Yes
No

Your honest answers to the following questions will help us place in the PS Small Group we feel will be the most helpful to you. Please check all boxes that apply.
Note: while we do our best to accommodate all who register, we reserve the right to accept or deny registration based on space, leadership ratios or suitability (in our opinion) that FS will be helpful for you.

Select all that apply
I have a strong need for control in my life
I find myself believing I’m unworthy
I’m a “people-pleaser”
Fear of failure paralyzes me into doing nothing
I protect others from the natural consequences of their behaviours and/or actions
There is one particular event in my life for which I feel intense guilt/shame that I cannot seem to shake and believe that I could never be forgiven for
I’m afraid to upset other people for fear that they will somehow hurt, reject or may leave me
I feel like I am personally responsible for other people’s lives and/or decisions
I make promises or threats that I don’t carry out (ie. if I ever do that again, I’m leaving.)
I have experienced feelings of fear/hatred towards the opposite sex
I have trouble believing/receiving God as a loving Father
I have gaps in memories from my childhood
I find myself avoiding relationships or struggling with intimacy (physical, emotional and if married, sexual intimacy)
I have struggled with chemical dependency
I comfort myself with food when feeling hurt, angry, depressed or bored
I feel alone in my problem
I find it hard to trust, especially those in authority

How much sobriety do you have? Explain please

I understand that my personal information may be given to pastoral and/or church staff, program leaders 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 prior consent. By checking “I Agree” below I indicate the I have read, understand and approve the above and that this information will be store 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.

I agree to the above *

Payment

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