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Heart Change Ministries – Client Initial Application

Can you receive texts?
YesNo

Married?
YesNo

Do you have children?
YesNo

Did you graduate?
YesNo


MentalPhysicalEmotionalSexual

Have you ever been hospitalized?
YesNo

Have you ever attempted suicide?
YesNo

Have you ever been involved in drugs?
YesNo

Do you struggle with misuse of prescription drugs?
YesNo

Are you challenged with low esteem?
YesNo

Are your debts past due?
YesNo

Have you trusted Jesus as Savior & Lord?
YesNo

Are you active in a church?
YesNo