SOZO MINISTRY APPLICATION

CONTACT INFORMATION
Name: / DOB: / Age:
Address: / City: / State: / Zip:
Email: / Phone:
Gender: Male Female / Church Attending:
Are you currently attending BSSM? Yes No
Why do you want to receive Sozo ministry?
Have you been seen at Bethel Sozo previously? Yes No
If Yes – By Whom? When?
Are you presently, or have you been in the past, been ministered to by any other ministry of Bethel Cleveland? Yes No
If Yes – With Whom? When?
Are you presently in counseling? Yes No
If Yes – Please specify:
Have you ever been in counseling? Yes No
If Yes – Please specify:
Were you referred to Sozo ministry? Yes No
If Yes – By Whom?
Will you be able to fast or pray for one week before your Sozo? Yes No
**Ask the Lord what He wants you to fast. Ex: a meal, watching TV, etc.
CONCERNS
What concerns bring you in?
When did the concerns begin?
Please describe significant events that occurred during the time of or since the concern started:
Are you having difficulties or stressors currently? Yes No
Please specify:
How do you typically handle stress?
Are there any behaviors, actions or habits you would like to change? Yes No
If Yes – Please explain:
TRIGGERS:(Listed below are common triggers, please check one or more boxes of things that trigger or “push your buttons.” Ask the Lord to highlight any additional triggers and record them below.)
Fear/Terror Anxiety Rejection Abandonment Humiliation
Betrayal Guilt Shame Anger/Rage Hopelessness
Helplessness
Additional triggers:
MEDICAL HISTORY
List any complications during your birth (Ex: Premature, C-Section, Birth Trama):
List any medical conditions or history:
List any mental illness or addictions (include any hospitalizations):
Do you have a learning disability? Yes No
If Yes – Please specify:
FAMILY HISTORY
List any history of mental illness or addictions in immediate or extended family (Ex: depression, anxiety, bi-polar, suicide attempts, alcoholism, drugs, ADHD, schizophrenia, etc.):
Are you adopted? Yes No
Briefly give parents’ marital history (Ex: divorces, step-parents, live-ins):
TRAUMA HISTORY
Have you witnessed domestic violence? Yes No
If Yes – Please specify:
Have you been verbally or physically abused? Yes No
If Yes – Please specify:
Signature: / Date:

**You may submit this completed form by dropping it off at one of our campuses, sending it via email or US mail at Sozo Ministry, 16670 E. Bagley Rd., Middleburg Heights, OH 44130.

For the value of the time spent ministering to you, there is a suggested donation of $75.00. You may send the donation when you return this application and Liability Release form to Bethel Cleveland, Attention: Sozo Ministry, 16670 E. Bagley Rd., Middleburg Heights, OH 44130. If you are emailing your form, you may pay the suggested donation at the time of your appointment. Thank you.

LIABILITY RELEASE FOR BETHEL CHURCH SOZO MINISTRY

This liability release form must be signed in the presence of your sozo leader, at the beginning of your sozo appointment.

I (name) acknowledge that team members from the Sozo Ministry of Bethel Church have voluntarily agreed to pray for me. I understand that this session is not a professional counseling meeting 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 understand that Bethel Church is a nonprofit Ohio corporation that makes no charge for its services. I further state that I have voluntarily sought assistance of my own initiative and that I am under no obligation to accept or reject any of the advice or help that I might receive from the team members of this ministry.

Our team members offer Biblical spiritual services to anyone who desires them regardless of ability to pay. Although there is no charge for our services, all efforts to build this ministry support and train our team members are paid directly from the donations of those receiving these services. We, therefore, have a suggested donation of $75.00 or more per visit. Your contributions to this ministry are greatly appreciated because they support our further development. Please make donations payable to Bethel Church. Thank you!

I understand that if I receive ministry from the Sozo Ministry, the team is committed to respect the disclosed information, but not to complete confidentiality. The information, as needed, may be shared with other leaders of Sozo Ministry so as to further your total healing process. This may include future meetings with spiritual mentors in the church to set appropriate boundaries for your personal and spiritual growth. I understand that Bethel Church mandatorily reports child and elder abuse to the proper authorities.

I agree to hold Bethel 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 from my involvement with Bethel Church.

THIS LIABILITY RELEASE FORM MUST BE SIGNED IN THE PRESENCE OF YOUR SOZO LEADER, AT THE BEGINNING OF YOUR SOZO APPOINTMENT.