I look forward to working with you as the Lord leads.  Please fill out the following information (in English) about yourself which will help us know how to pray for you.  Do not share anything with me that you are not comfortable sharing at this time.  Whatever you share will be held in confidence and taken to the Lord in prayer. Any information submitted to Bethel Colony of Mercy is held in the strictest confidentiality laws pertaining
to Recovery Centers.

Cathi Loss
Bethel Colony Internet Ministry

Now to Him who is able to keep you from stumbling, And to present you faultless before the presence of His glory with exceeding joy, To God our Savior, Who alone is wise, be glory and majesty, dominion and power, both now and forever. Amen. – Jude 1:24-25


Enter the information below and press submit.

COUNSELING AGREEMENT

I, the undersigned, agree to the counseling methods and procedures offered through Bethel Colony of Mercy, Inc.  I understand that my counseling may involve prayers, Bible reading, Scripture writing, spiritual warfare, Biblically based homework, and the use of inexpensive Christian resources.  I understand that the basis for the counseling is the infallible, inerrant, plenary word of God (The Bible) and that the ministry emphasizes the moral absolutes depicted in the Scriptures and not moral relativism.

Signed (required)
  

Dated (required)


“Not lagging behind in diligence, fervent in spirit, serving the Lord; rejoicing in hope, persevering in tribulation, devoted to prayer” – Romans 12:12

Name (required)

Age

Email (required)

MARK ANY OF THE FOLLOWING THAT APPLY TO YOU

ADULTERY

PORNOGRAPHY

A QUITTER

A COMPLAINER

SEX OUTSIDE MARRIAGE

OUIJA BOARD

WITCHCRAFT

BLACK MAGIC

SEANCES

LUST/FANTASY

SATAN WORSHIP

ASTROLOGY

HOMOSEXUAL

MASONIC PLEDGE

LAZY

DUNGEONS & DRAGONS

TEA LEAVES

PALM READING

 

DESCRIBE YOURSELF IN THE PAST YEAR:

DESCRIBE YOURSELF:

MY BIGGEST PROBLEM IS:

MY SECOND BIGGEST PROBLEM IS:

MY THIRD BIGGEST PROBLEM IS:

HAVE YOU DONE WRONG TO ANYONE? YesNo

HAVE YOU EVER PHYSICALLY HURT ANYONE? YesNo

HAVE YOU EVER TRIED TO COMMIT SUICIDE? YesNo

DO YOU DRINK ALCOHOL? YesNo

DO YOU -- USE DRUGS? YesNo

HAVE YOU EVER BEEN MARRIED? YesNo

DO YOU HAVE A GIRLFRIEND OR BOYFRIEND? YesNo

HAVE YOU EVER BEEN DIVORCED? YesNo

ARE YOU DEPRESSED A LOT? YesNo

DO YOU BELIEVE THE PRINCIPLES AND PRECEPTS SET FORTH IN SCRIPTURE ARE WITH-OUT ERROR ? YesNo

DO YOU BELIEVE IN GOD? YesNo

DO YOU BELIEVE GOD HAS THE RIGHT TO TELL YOU HOW TO LIVE? YesNo

ARE YOU WILLING TO COME UNDER THE AUTHORITY OF THE WORD OF GOD AND ALLOW IT TO DIRECT YOUR LIFE? YesNo

MARK ANY OF THE FOLLOWING THAT YOU THINK YOU MUST DO TO GET TO HEAVEN

GO TO CHURCH

NEVER HURT ANYBODY

BE KIND TO THE POOR

GO TO THE ALTAR

BE A GOOD PERSON

DO THE BEST YOU CAN

LIVE BY THE GOLDEN RULE

GET BAPTIZED

OBEY THE TEN COMMANDMENTS

ALL OF THE ABOVE

NONE OF THE ABOVE

Other