SHSH Application Please complete the information below to the best of your ability. Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmail *PhoneOccupationHours Worked A Week: *Employed By:Marital Status: *SingleMarriedSeparatedDivorcedWidowedRemarriedIf married, does your spouse desire ministry? *YesNoIf not, please explain:Presently living with: *ParentsSpouseAloneOtherIf other, please specify:Name of spouse:Occupation of spouse:Have you ever been separated? *YesNoIf so, when?Date Married:Your Age: *Spouse's Age: Medical & Religious BackgroundAre you receiving medical treatment? *YesNoIf yes, for what purposes?Are you currently taking medication prescribed for emotional reasons? *YesNoIf yes, what medication?Do you have any serious medical conditions? *YesNoIf yes, what are they?Are you currently a member of a church? *YesNoDescribe your present relationship with the Lord: *Your Birth ConditionsSelect if any of the situations were present when you were conceived or during your mother’s pregnancy: *My mother dietedMy mother took drugsMy mother smokedMy mother drank alcoholMy mother drank caffeineMy mother experienced traumaI was conceived by rapeMy mother was in poor healthMy mother lost a loved oneMy father died or leftThere was a lot of fighting in the homeMy parents were too young; not ready for childrenMy parents wanted a child of the opposite sexMy mother did not want meMy father did not want meI was given up for adoptionI was the next child after a miscarriage or abortionI was conceived out of wedlockThere were premature complicationsBreech deliveryCord around my neck during deliveryForceps deliveryLabor was inducedI suffered a loss of oxygen during deliveryC-section deliveryOtherIf you selected "other", please explain:Family BackgroundWhat country or countries did your ancestors originally come from? *What prominent cultural and/or ethnic backgrounds are in your ancestral lines? *What are the church backgrounds of your ancestors? *What areas within America have they primarily lived? *Were they possibly connected with slavery (IE: Slaves? Slave owners? Slave traders?) *Is it possible they were involved in unfair business practices? *Is it possible they were involved in the occult? *Family PatternsCheck all that apply *Lack of intimacy (in marriage, other)Lack of communication between spousesLack of communication between parentsLack of communication with parents/childMen dominant over womenWomen dominant over menBroken marriages/divorceFamily secretsPride and arroganceUnfulfilled lives and/or destiniesBroken promises (relationships/finances)Men/women workaholicsSuccess/failure cyclesDeceptive business practicesBusiness, financial or other lossesCodependencyChildren favored, idolizedChildren not valued, neglectedChildren taking care of parentsChildren dishonoring parentsSibling rivalry, fights, feudsChronic illness/sicknessPremature deathsMost received salvationMost were not savedIdolatry of AbuseIdolatry of AddictionChoice 31Parental RelationshipsNatural Parents *MarriedSeparatedDivorcedNever MarriedRate Your Parent's Marriage: *UnhappyAverageHappyVery HappyIf parents separated or divorced, how old were you at the time? Father remarried when you were age:Mother remarried when you were ageYou Lived With: *MotherFatherFosterOther Family MemberIf you lived with another family member or someone else, who were they? Step-parents (if applicable)MarriedSeparatedDivorcedFather deceased? *YesNoIf yes, how old were you at the time?Mother deceased? *YesNoIf yes, how old were you at the time?What kind of relationship did/do you have with your father? *What kind of relationship did/do you have with your mother? *On a scale of 1 to 10, indicate how much you feel your FATHER loved you:Rate 1 out of 10Rate 2 out of 10Rate 3 out of 10Rate 4 out of 10Rate 5 out of 10Rate 6 out of 10Rate 7 out of 10Rate 8 out of 10Rate 9 out of 10Rate 10 out of 10On a scale of 1 to 10, indicate how much you feel your MOTHER loved you: Rate 1 out of 10Rate 2 out of 10Rate 3 out of 10Rate 4 out of 10Rate 5 out of 10Rate 6 out of 10Rate 7 out of 10Rate 8 out of 10Rate 9 out of 10Rate 10 out of 10Who has caused you the most pain or disappointment? Describe what happened: *List the main issues in your life that you and God are working on at this time: *General Questions About Your MotherDid you mother want you? *YesNoDid she plan you? *YesNoWas your mother under stress when she conceived you? *YesNoIf yes, how so?Was your mother fearful, depressed, angry, sickly or mourning during pregnancy? *YesNoWere you the next child after a miscarriage or abortion? *YesNoWas your mother married? *YesNoWas your father around during your mother’s pregnancy? *YesNoWere you given up for adoption? *YesNoWere you premature, experience other complications during birth? *YesNoIf yes, please explain:Did your mother have any accidents/trauma during pregnancy? *YesNoIf yes, please explain:Did your mother engage in any witchcraft or occult practices? *YesNoDid your mother smoke, drink or do drugs during her pregnancy? *YesNoWas your mother a “huggy” kind of person? *YesNoDid your mother verbally abuse you? *YesNoDid your mother sexually abuse you? *YesNoDid your mother physically abuse you? *YesNoGeneral Questions About Your FatherWas he always there for you, as a child from birth to 18? *YesNoDid he ever verbally abuse you? *YesNoIf yes, please explain how:Did he ever physically or sexually abuse you? *YesNoIf yes, please explain how:Did he show more love to your sibling than you? *YesNoDid he hug you and tell you he loved you? Please rate below on the scale 1 – 5 *Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5Did he reject you in any way? *YesNoPlease explain: *Was he away a lot? *YesNoWas he work a lot? *YesNoDid he support your pursuit of interests like sports, art, music? *YesNoHow did he support?Did he want a boy or girl? *BoyGirlNeitherDid you disappoint him? *YesNoDid he treat your mother well? *YesNoIf not, how?Was your father in your life from the beginning? *YesNoIf not, was he involved at some point? When? Do you hold unforgiveness toward your father? *YesNoIf so, why?Did you have a stepfather or another man figure in your life as a child? *YesNoIf so, how did he treat you?General Questions About Your Step-Father*Skip to the next section if not applicable*Was he always there for you, as a child from birth to 18? *YesNoDid he ever verbally abuse you? *YesNoIf so, how?Did he ever physically or sexually abuse you? *YesNoIf so, how?Did he show more love to your sibling than you? *YesNoDid he hug you and tell you he loved you? Please rate below on the scale 1 – 5 *Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5Did he reject you in any way? *YesNoIf so, how? Was he away a lot? *YesNoDid he work a lot? *YesNoDid he support your pursuit of interests like sports, art, music? *YesNoIf so, how?Did he want a boy or girl? *BoyGirlNeitherDid you disappoint him? *YesNoDid he treat your mother well? *YesNoIf not, how?Was your step-father in your life from the beginning? *YesNoIf not from the beginning, was he involved at some point? When? Do you have unforgiveness toward your step-father? *YesNoIf so, why?Did you have another man figure in your life as a child? *YesNoIf so, how did he treat you?Open Doors - Abandonment(Check if applicable to: Father, Mother, or Self)DivorceFatherMotherSelfEmotional AbandonmentFatherMotherSelfNot WantedFatherMotherSelfRejectionFatherMotherSelfSelf-PityFatherMotherSelfSeparationFatherMotherSelfUnprotectedFatherMotherSelfFatherlessnessFatherMotherSelfOut of WedlockFatherMotherSelfOpen Doors - Anger(Check if applicable to: Father, Mother, or Self)AbandonmentFatherMotherSelfDisappointmentFatherMotherSelfFeudingFatherMotherSelfHatredFatherMotherSelfHostilityFatherMotherSelfMurderFatherMotherSelfRageFatherMotherSelfResentmentFatherMotherSelfRevengeFatherMotherSelfSpoiled as a childFatherMotherSelfTemper TantrumsFatherMotherSelfViolenceFatherMotherSelfOpen Doors - Performance(Check if applicable to: Father, Mother, or Self)ComparisonFatherMotherSelfCompetitionFatherMotherSelfCovetingFatherMotherSelfEnvy/JealousyFatherMotherSelfPeople PleasingFatherMotherSelfPerfectionismFatherMotherSelfPossessivenessFatherMotherSelfStrivingFatherMotherSelfWorkaholicFatherMotherSelfOpen Doors - Shame(Check if applicable to: Father = F, Mother = M, or Self)EmbarrassmentFatherMotherSelfGuiltFatherMotherSelfBorn out of WedlockFatherMotherSelfRegretFatherMotherSelfSelf-CondemnationFatherMotherSelfSelf-HateFatherMotherSelfSelf-PityFatherMotherSelfOpen Doors - Rejection(Check if applicable to: Father, Mother, or Self)Expected RejectionFatherMotherSelfPerceived RejectionFatherMotherSelfSelf-RejectionFatherMotherSelfInsecurityFatherMotherSelfOpen Doors - Unworthiness(Check if applicable to: Father, Mother, or Self)InadequacyFatherMotherSelfInferiorityFatherMotherSelfInsecurityFatherMotherSelfSelf-CondemnationFatherMotherSelfSelf-HateFatherMotherSelfSelf-PunishmentFatherMotherSelfSelf-SabotageFatherMotherSelfOpen Doors - Addictions & Dependencies (Check if applicable to: Father, Mother, or Self)AlchoholFatherMotherSelfExcessive CaffeineFatherMotherSelfCocaineFatherMotherSelfComputersFatherMotherSelfDowners/UppersFatherMotherSelfFoodFatherMotherSelfGamblingFatherMotherSelfMarijuanaFatherMotherSelfNicotineFatherMotherSelfShopping/OverspendingFatherMotherSelfPrescription DrugsFatherMotherSelfSleep MedicationFatherMotherSelfSportsFatherMotherSelfStreet DrugsFatherMotherSelfTelevisionFatherMotherSelfVideo GamesFatherMotherSelfSocial MediaFatherMotherSelfOpen Doors - Death(Check if applicable to: Father, Mother, or Self)AbortionFatherMotherSelfAccidentsFatherMotherSelfDeath WishFatherMotherSelfDeath to Destiny/DreamsFatherMotherSelfMiscarriageFatherMotherSelfMurderFatherMotherSelfPremature DeathFatherMotherSelfSuicide/Suicide AttemptFatherMotherSelfSuicide Fantasies FatherMotherSelfOpen Doors - Bitterness(Check if applicable to: Father, Mother, or Self)BlamingFatherMotherSelfComplainingFatherMotherSelfCritical/JudgingFatherMotherSelfGossipFatherMotherSelfOffendedFatherMotherSelfRidiculeFatherMotherSelfUnforgivenessFatherMotherSelfOpen Doors - Depression(Check if applicable to: Father, Mother, or Self)DaydreamingFatherMotherSelfDiscouragementFatherMotherSelfDespair/HopelessnessFatherMotherSelfLaziness/OversleepingFatherMotherSelfPassivityFatherMotherSelfSelf-PityFatherMotherSelfWithdrawal/IsolationFatherMotherSelfOpen Doors - Occult(Check if applicable to: Father, Mother, or Self)Accident ProneFatherMotherSelfAstral ProjectionFatherMotherSelfAstrology/HoroscopesFatherMotherSelfDemon WorshipFatherMotherSelfDivinationFatherMotherSelfEastern MeditationFatherMotherSelfFortune Telling/SéancesFatherMotherSelfFreemasonryFatherMotherSelfHypnosisFatherMotherSelfMental TelepathyFatherMotherSelfOccult DedicationsFatherMotherSelfOuija BoardFatherMotherSelfPalm Reading/Tarot CardsFatherMotherSelfReading Tea LeavesFatherMotherSelfSatanic WorshipFatherMotherSelfVoodoo/SanteriaFatherMotherSelfWitchcraftFatherMotherSelf“Bloody Mary” ritualFatherMotherSelfCast a spell or hexFatherMotherSelfDrank blood or urineFatherMotherSelfHeard violent rap musicFatherMotherSelfHeard satanic rock musicFatherMotherSelfOccult jewelry or booksFatherMotherSelfHeard voicesFatherMotherSelfHeard “Kill yourself”FatherMotherSelfJoined a covenFatherMotherSelfPlayed Dungeons & DragonsFatherMotherSelfMade a blood pact or vowFatherMotherSelfMartial Arts, Tai Chi or YogaFatherMotherSelfWitnessed a sacrificeFatherMotherSelfSeen demonsFatherMotherSelfSeen horror moviesFatherMotherSelfUsed MantrasFatherMotherSelfVisited Indian burial groundsFatherMotherSelfAcupunctureFatherMotherSelfBody PiercingFatherMotherSelfBuddhism or HinduismFatherMotherSelfElks or Moose LodgeFatherMotherSelfIndian Occult RitualsFatherMotherSelfIslamFatherMotherSelfJehovah’s WitnessesFatherMotherSelfKabbalahFatherMotherSelfKnights of ColumbusFatherMotherSelfMardi GrasFatherMotherSelfMormonismFatherMotherSelfNew Age MovementFatherMotherSelfRastafariansFatherMotherSelfTattoosFatherMotherSelfOpen Doors - Control(Check if applicable to: Father, Mother, or Self)Anorexia or BulimiaFatherMotherSelfCuttingFatherMotherSelfDenialFatherMotherSelfDomineeringFatherMotherSelfEnablingFatherMotherSelfFalse ResponsibilityFatherMotherSelfFemale/Male ControlFatherMotherSelfManipulationFatherMotherSelfPassive AggressionFatherMotherSelfPassivityFatherMotherSelfPossessivenessFatherMotherSelfPride “I Know Best”FatherMotherSelfSelfishnessFatherMotherSelfThrough IntimidationFatherMotherSelfThrough Silent TreatmentsFatherMotherSelfThrough TreatsFatherMotherSelfOpen Doors - Fear(Check if applicable to: Father, Mother, or Self)AnxietyFatherMotherSelfHeavinessFatherMotherSelfIntimidationFatherMotherSelfOver-SensitivityFatherMotherSelfParanoiaFatherMotherSelfPhobiaFatherMotherSelfSuperstitionFatherMotherSelfTormentFatherMotherSelfFear of AuthoritiesFatherMotherSelfFear of being abusedFatherMotherSelfFear of being aloneFatherMotherSelfFear of being a victimFatherMotherSelfFear of conflictFatherMotherSelfFear of deathFatherMotherSelfFear of demonsFatherMotherSelfFear of failureFatherMotherSelfFear of the futureFatherMotherSelfFear of infirmitiesFatherMotherSelfFear of intimacyFatherMotherSelfFear of losing controlFatherMotherSelfFear of man (People)FatherMotherSelfFear of rejectionFatherMotherSelfFear of sexual inadequacyFatherMotherSelfFear of successFatherMotherSelfFear of violenceFatherMotherSelfOpen Doors - Anxiety(Check if applicable to: Father, Mother, or Self)Fatigue/WearinessFatherMotherSelfImpatienceFatherMotherSelfNervousnessFatherMotherSelfPanic AttacksFatherMotherSelfRestlessnessFatherMotherSelfStress/WorryFatherMotherSelfOpen Doors - Infirmities/Disease(Check if applicable to: Father, Mother, or Self)Allergies/Sinus problemsFatherMotherSelfAsthmaFatherMotherSelfBarrenness/MiscarriageFatherMotherSelfBone ProblemsFatherMotherSelfCancerFatherMotherSelfCirculatory ProblemsFatherMotherSelfDementiaFatherMotherSelfDiabetesFatherMotherSelfFemale ProblemsFatherMotherSelfHeart or lung ProblemsFatherMotherSelfJoint ProblemsFatherMotherSelfMigrainesFatherMotherSelfTeeth/Gum ProblemsFatherMotherSelfOpen Doors - Sexual Issues(Check if applicable to: Father, Mother, or Self)AdulteryFatherMotherSelfBestialityFatherMotherSelfBisexualityFatherMotherSelfDemonic Sex/Fantasy LustFatherMotherSelfFrigidityFatherMotherSelfHomosexualityFatherMotherSelfIncestFatherMotherSelfMasturbationFatherMotherSelfPornographyFatherMotherSelfPromiscuity/PerversionFatherMotherSelfProstitutionFatherMotherSelfOpen Doors - Identity Issues(Check if applicable to: Father, Mother, or Self)Effeminate MalesFatherMotherSelfGender ConfusionFatherMotherSelfHomosexualityFatherMotherSelfLoss of selfFatherMotherSelfSelf-DeceptionFatherMotherSelfSelf-HateFatherMotherSelfTranssexualFatherMotherSelfTransvestiteFatherMotherSelfOpen Doors - Mental Problems(Check if applicable to: Father, Mother, or Self)ADD/ADHDFatherMotherSelfBipolar DisorderFatherMotherSelfConfusionFatherMotherSelfHallucinationsFatherMotherSelfMind BlockingFatherMotherSelfMind RacingFatherMotherSelfObsessive-CompulsiveFatherMotherSelfParanoiaFatherMotherSelfSchizophreniaFatherMotherSelfOpen Doors - Pride(Check if applicable to: Father, Mother, or Self)Arrogance/SuperiorityFatherMotherSelfConceitFatherMotherSelfPrejudiceFatherMotherSelfSelf-CenterednessFatherMotherSelfSelf-RighteousnessFatherMotherSelfSuppression of OthersFatherMotherSelfVanityFatherMotherSelfOpen Doors - Trauma(Check if applicable to: Father, Mother, or Self)Abuse, EmotionalFatherMotherSelfAbuse, MentalFatherMotherSelfAbuse, PhysicalFatherMotherSelfAbuse, SexualFatherMotherSelfAbuse, SpiritualFatherMotherSelfAbuse, VerbalFatherMotherSelfAccidentsFatherMotherSelfDivorceFatherMotherSelfIncarcerationFatherMotherSelfPost-Traumatic Stress DisorderFatherMotherSelfTortureFatherMotherSelfViolenceFatherMotherSelfWarFatherMotherSelfExamples Of Ungodly BeliefsThese are a few examples of ungodly beliefs that can be in the depths of your thoughts. If any thoughts not listed rise up, please add them. Ask the Holy Spirit to help you identify them. They may be passed from generation to generation, transferred through other people as a result of soul ties or from past experiences. Check the ones that apply.I don’t belong. I will always be on the outside (left out).My feelings don’t count. No one cares what I feel.No one will love me or care about me just for myself.I will always be lonely. The special person in my life will not be there for me.The best way to avoid hurt, rejection, etc. is to isolate myself.I am not worthy to receive anything from God.I am the problem. When something is wrong, it is my fault.I’m a bad person. If you knew me, you would reject me.God doesn’t care if I have a secret life as long as I appear good.I have to plan every day of my life. I can’t relax.I am unattractive. God short-changed me.It’s impossible for me to lose weight. I’m just stuck.I will always be crazy, shy, insecure, fearful, etc.I will never be known or appreciated for my real self.I can’t change and be as God really wants me to be.I am a loser and will never succeed. I don’t deserve to; I am a bad person.I will always be this way. I can never change.I must guard what I say since anything I say may be used against me.I have to hide my feelings. I will not be vulnerable, humiliated or shamed againIf you hurt me, I will punish you by cutting you off.Authority figures will just use me or abuse me.I am out there all alone. If I need help there is no one there for me.I will never let anyone get close to me again. They will only hurt me.God loves other people more than me.I can never do enough to please God.No one really cares for me. It doesn’t matter whether I do right or wrong.I hate myself. I’m not worth saving. I’m just a mess-up.No matter what I do, I can never get it right.People like others more. No matter what I do, I‘ll never be accepted or approvedI don’t deserve to be blessed. I’ve done so many wrong things.List any ungodly beliefs you have that are not already listed above.Word Curses, Judgements Ask the Holy Spirit to bring back to your remembrance any Word Curses spoken by others to you, from you to yourself, or from you to others, particularly ones that relate to your problem(s). Write them:Curses Spoken by Others toward MeCurses I have Spoken (or Thought) about Myself or OthersOther RelationshipsBriefly describe your current relationship with:Parents (if living)Adult ChildrenSiblingsCo-workers/EmployerAdded InformationPlease Complete The Following:The most important thing to me is...I worry about...What I do best is...I have sometimes felt guilty about...I have been criticized for...What makes me angry is...My biggest mistakes were...My job...What makes me nervous is...My personality would be better if...I often felt that mother...Jesus Christ...My temper...My childhood...Prayer is...My biggest disappointment...To me, sex is...I would be better liked if...I often felt that my father...God to me is...My child/children...Women are...What hurts me most is...My brother(s) and sister(s)...My biggest problem in life is...Men are...Supplemental Information Have you been hypnotized or involved in New Age practices or own new age jewelry? *YesNoHave you had an imaginary friend or a spirit offer you guidance or companionship? *YesNoHave you heard voices in your mind or nagging thoughts condemning you that were foreign to what you believe or feel? *YesNoWhat other spiritual experiences have you had that you would consider out of the ordinary?Have you had anorexia or bulimia or any other eating disorder like overeating? *YesNoHave you had (or still have) irregular sleeping patterns and nightmares? *YesNoHave you ever witnessed or been involved in an extremely traumatic event? *YesNoAre there people from your past or in your life now that you need to forgive?Lastly, please provide any additional information that you believe would be helpful in the ministry process.Submit 1520 Royal Palm Square Blvd,Suite 320Fort Myers, FL 33919Mon-Fri, 9:00am – 4:00pm 239.244.3912 What we offer: Inner HealingMarriage CounselingLife CoachingSpiritual CounselingFit & Free Weight Loss What people are saying The Stop Hurting Start Healing ministry is the best thing I have done in my life. —Maria R. Prayer broke [the curse of judgment] in my life. —James T. The restoration in my life internally and externally is beyond measure! — Janice K. Contact Us: Name Email Address Phone Message Submit
