Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.About This Form & What You Need to KnowPURPOSE The purpose of this form is to request Trauma Healing from Bread of Life. If you’ve experienced trauma and are seeking deeper healing, this prayer approach is designed to help. We also use it when someone has received prayer before but still feels they need more healing. Sometimes wounds from earlier in life can keep the healing process from being fully realized. Trauma Healing is meant to gently address these areas. Please complete this questionnaire to request Trauma Healing. DISTRACTION FREE NOTICE To ensure a peaceful and distraction-free environment for everyone during the prayer session, we kindly ask that you make arrangements for your children beforehand, as childcare is not available. If you have someone accompanying you, they are welcome to wait in a separate prayer room during the session. Thank you for your understanding and cooperation! CONFIDENTIALITY NOTICE The information you provide will remain confidential and will be used solely to help us plan and prepare for your session. Only those involved in organizing your ministry team and members of your prayer team will have access to it. DUTY TO WARN/DUTY TO NOTIFY NOTICE We may disclose information without your consent to prevent you from harming yourself or others. We are legally required to report ongoing domestic violence, and abuse or neglect of children, elderly individuals and people with disabilities, including human trafficking. LIABILITY RELEASE NOTICE We will ask you to sign a Liability Release before your session. This is a legal agreement that protects us from being held liable for any injuries, damages, or losses incurred by you during your prayer session. Basic InformationName *FirstLastEmail *Phone Number *YOUR REASONS FOR REQUESTING A SESSION WITH USWhat issues or problems led you to seek this type of healing?On a scale of 1 to 10, rate how much this is affecting you. Selected Value: 1 (1 means affects you very little, 10 means affects you greatly)Briefly describe what happened. How is this affecting you? Do you know of any family members with this same issue? Have you pursued any healing for this already? How? Submit