Aletheia Ministries Application Form

Personal Information

Date of Application:

First Name:

Last Name:

Email:

Phone:

Age:

Gender:

Address:

City:

State/Province:

ZIP/Postal Code:

Emergency Contact Phone:

Emergency Contact Email:

Ministry Information

Church Attending:

Pastor's Name:

How did you hear about Aletheia Ministries? (Be specific)

Why would you like to receive ministry?

Have you received ministry from Aletheia Ministries in the past?

_____ Yes_____ No

Approx date of ministry:

If able, would you be willing to fast or pray one week prior to your ministry session?

_____ Yes_____ No

Professional Care Information

Are you currently under the care of a professional counselor, psychologist, or psychiatrist?

_____ Yes_____ No

Have you been diagnosed with any condition?

_____ Yes_____ No

If yes to either, please describe:

Are you currently taking any medication prescribed through this care?

_____ Yes_____ No

Availability

Please indicate which time works best for you to come in for ministry:

Tuesday mornings from 10 am – noon

_____ Yes_____ No

Thursday evenings from 7 pm – 9 pm

_____ Yes_____ No

Liability Release Form

I acknowledge that team members from Aletheia Ministries, a ministry of St. Giles Evangelical Presbyterian Church, have voluntarily agreed to pray for me. I understand that this ministry session is not a professional counseling meeting and that none of the Aletheia team members are licensed counselors. I understand that the Aletheia Ministries team members are, to the best of their ability, doing what they can to help me achieve more freedom in my life. As such, I agree to hold Aletheia Ministries and the home church, St. Giles Presbyterian EPC, Charlotte NC, harmless and release them from any liability claims.

I understand that this experience may produce a mix of emotions in me. I also understand that I am free to stop or alter the session at any time and for any reason. In receiving ministry from Aletheia Ministries, the team is committed to respect information disclosed during a ministry session, and will hold my confidentiality within Aletheia Ministry team members.

I acknowledge that this ministry experience is being offered to me free of charge and at my request of Aletheia Ministries. Although there is no charge for our services, efforts to build and develop this ministry and train our team members are paid directly from donations received for these services. Should you desire to make a donation, please make checks payable to: St. Giles Presbyterian Church, designated for: Aletheia Ministries. All donations are tax deductible. Once your paperwork is received, we will contact you to schedule and appointment. Donations are greatly appreciated.

I agree to hold Aletheia Ministries, its home church, St. Giles Presbyterian Church and its team members free from any and all liability, loss or damage of any kind that may arise as a result of assistance which I have received or will receive.

First Name:

Last Name:

Date:

Signature:

Aletheia Ministries Application Form

Personal Information

Ministry Information

Professional Care Information

Availability

Liability Release Form

Ministry Application

Step 1 of 3

Emergency Contact

Ministry Information

Professional Care Information

Availability