Name *

First Name

Last Name

Phone *

(###)

###

####

Gender *

Male

Female

Currently seeing a therapist / counselor? *

Yes

No

Please check any of the following that currently apply.

Anxiety

Physically Abused

Increase/Decrease Appetite

Addictive Behavior

Suicidal Ideation

Depression

Sexually Abused

Hearing Voices

Alcohol Abuse

Recent Loss

Criminal Record

Sexual Promiscuity

Headaches

Physically Abusive

Angry Outbursts

Drug Abuse

Suicide Attempts

Sleep Disturbance

Sexually Abusive

Occult Involvement

What type of appointment are you requesting? *

In-person in Nashville

Phone

Video/Skype

Liability Release for Legacy Nashville *

I acknowledge that Legacy Nashville Prayer Team members have voluntarily agreed to pray for me using inner healing methods and, when appropriate, pastoral counseling. I understand this is not a professional counseling session and that none of the team members are licensed counselors. I understand that these team members are, to the best of their ability, doing what they can to help me achieve more freedom in my life. I have sought assistance of my own accord and am under no obligation to accept or reject any advice or help I may receive. I understand that if I receive ministry from Legacy Nashville, the team is committed to respect the disclosed information, unless the two issues mentioned below are discussed. I understand that the team is required by law to report any intent of a person to take harmful, dangerous, or criminal action against another person or themselves and any act of child or elderly abuse or neglect. I agree to hold Legacy Nashville and its team members free from any liability, loss, or damage arising from assistance I have received or my involvement with Legacy Nashville. I have read and understand this disclaimer and release of liability and have signed it as my free and voluntary act. Signature: Must be signed by applicant or legal guardian if applicant is a minor (under 18 years of age).

I verify that I have filled out this form and signed it on my own behalf, unless I am a legal guardian or a minor. *

Yes

No