Heart Change Ministries – Client Initial Application
Full Name (required)
Can you receive texts?
Husband/Wife Name or next of kin
Do you have children?
Ages (comma separated)
Why are you seeking help from Heart Change?
What school did you attend?
Did you graduate?
Have you attended college or trade school?
List your job history
List your skills
List your hobbies
Have you ever been abused?
Have you ever been hospitalized?
Have you ever attempted suicide?
Have you ever been involved in drugs?
Drug of choice?
Do you struggle with misuse of prescription drugs?
Are you challenged with low esteem?
Are your debts past due?
Have you trusted Jesus as Savior & Lord?
Are you active in a church?
First Baptist Church of West Valley City
Utah/Idaho Southern Baptist Association
Women's Missionary Union
Christian Women/Men Job Corp
...And Many Others!
Tuesday through Friday 10-6pm
Weekends and Evening Hours Available
Please telephone for appointment
Heart Change Ministries
3831 South 2700 West,
West Valley City, Utah 84119
(Program Director Sonya Usher)