Sozo Intake Form Date of application * MM DD YYYY Name * First Name Last Name Email * Phone * (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country What's the best way to contact you? * Call me Text me Email me Age * Gender * Female Male What is the name of the church you attend? * Who referred you? First Name Last Name Why do you desire a Sozo? * How would you describe your pain? Why do you think you are dealing with this problem? When did you notice this was a problem? Previous Sozo ministry if applicable Reason for Financial Assistance * Income * Less than $25,000.00 $25,000.00 - $50,000.00 $50,000.00 - $75,000.00 $76,000.00 or more Other Ministries If applicable Sozo Team * Team members assigned to you may be the same gender or a male/female team. Please list your preference (if any) No preference Same gender team Male/Female team Sozo location * Which is preferred for your Sozo ministry? St. Charles, Life Church Morris, Life Church I understand and I am fully aware that this session with the ministerial staff or other Biblical support team members is neither legal, medical, or psychological counseling, but is prayer that is based upon the Word of God. I understand that Life Church Sozo services are not designed to replace conventional treatment methods of medical or psychological conditions. I understand that Life Church Sozo and its affiliates are not licensed physicians or psychologists or providers of medical or psychological services. I am responsible for my own health care decision-making by obtaining any necessary consultations with appropriately licensed healthcare professionals such as physicians and psychologists. I acknowledge that I have not been hospitalized for any psychotic condition within the last ten (10) years, nor have charges been brought against me based on my behavior. I understand that Life Church Sozo has the right to refuse to continue delivering services at any time for any reason whatsoever and will refund my payment in full for the portion of unused services. I understand that Life Church Sozo is - to the best of its ability and within its permitted scope of services - doing what they can to help me achieve more freedom in my life. * Please read and agree to the terms above. Yes, I agree to these terms. Electronic Signature * Entering your name below is considered your electronic signature. First Name Last Name Thank you!