Sex *

Male

Female

Phone *

(###)

###

####

Date of Birth *

MM

DD

YYYY

Have you ever:

Check all that apply.

Spent time in jail/prison

Been sexually active (if not married)

Been convicted of a crime

Used drugs

Been involved in Satanism, witchcraft, or the occult

Taken depression or behavioral medication

Been involved in homosexual activities

Intentionally inflicted harm on yourself

Attempted suicide

Been pregnant or fathered a child

Participated in gang related activities

Had an eating disorder

Had psychiatric care

Pastor/Spiritual Leader *

First Name

Last Name