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Narc Free Living Coaching Intake Form
So that we can better understand your unique situation and needs, please complete the following intake form within 48 hours of your initial coaching session.
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Email
*
Your email
Name (Full)
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
What denomination do you belong to?
*
Your answer
How did you hear about Narc Free Living?
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Friend or Family
Website
Newsletter
Event
Other
Required
Primary Concern (please summarize your situation)
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Your answer
Do you understand that deliverance and coaching does not replace discipleship, a personal relationship with YAH, a repentant, & consecrated life?
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Yes
No
I would like to discuss this more at our session.
Required
Are you currently living in sin? Check all that apply.
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No
Yes, and I am ready to repent.
Yes, and I am not ready at this time to stop.
I understand the consequences of sin & legal rights to the enemy.
I would like to discuss this more at our session.
Required
Is there anyone in your life that you struggle to forgive?
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Yes
No
Unsure
Required
Are you a Believer and Follower of Jesus Christ (Yahshua)?
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Yes
No
Unsure
Required
What 1-3 short-term goals would you like to accomplish during coaching?
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Your answer
What will it look like once you've meet your goal(s) as identified above?
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Your answer
On a scale of 1 to 3, how would you rate your current commitment to being FREE?
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Not Committed
1
2
3
Very Committed
The following symptoms may indicate spiritual oppression. Please check any symptoms that resonate with you.
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Psychic abilities, clairvoyance, divination; feeling of having "special powers."
Inward perception of a separate personality, name or voice.
Fearful, repetitive night visitations by an evil presence.
Difficulty participating in prayer; agitation, nausea, anger, rebellion, etc.
Uncontrolled thoughts/impressions, e.g., sexual perversion, cursing, violence. Uncontrollable compulsive behaviors: sexual sin, anger, chemical indulgence. Preoccupation with thoughts of death, despair and hopelessness.
Uncontrollable, irrational, paralyzing fear.
Unusual, non-typical emotional expressions, e.g., laughter, sadness, crying, anger.
Extreme nervousness or negative reactions at the mention of the name of Jesus.
Participation in witchcraft, the occult, psychic mediums, tarot reading, voodoo, etc.
Secret societies, Greek organization, and false religions
Other:
Required
Do you believe there are narcissists in your bloodline/family? If so, Who?
*
Your answer
Are you working with a therapist or any other ministers (coaches, psychiatrists, spiritual advisers)? How long? Is the relationship beneficial? (Please provide the type, length of time working with person, and whether you believe it has been/or is currently helpful)
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Your answer
Rate degree of stress/urgency for any applicable areas - 1 {low) to 5 (high):
Low
Medium
High
Anger
Anxiety or Depression
Career Decision
Chronic Illness
Drug Addictions (Alcohol or other illicit substances)
Eating Disorder
Financial Crisis
Homosexuality
Insomnia
Loneliness
Low Self-Esteem
Occult Oppression
Marital or other Relationship Problems
Sexual Identity Issues
Soul Ties
Workaholism
Unforgiveness/Bitterness
Low
Medium
High
Anger
Anxiety or Depression
Career Decision
Chronic Illness
Drug Addictions (Alcohol or other illicit substances)
Eating Disorder
Financial Crisis
Homosexuality
Insomnia
Loneliness
Low Self-Esteem
Occult Oppression
Marital or other Relationship Problems
Sexual Identity Issues
Soul Ties
Workaholism
Unforgiveness/Bitterness
Clear selection
Please re-confirm the best email to reach you at:
*
Your answer
A copy of your responses will be emailed to the address you provided.
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