top of page

Check the issues that pertain to you: rate degree of stress/urgency for applicable areas, Indicate in the range of 1 – 10  ( 1 being low, and 10 being high stress/urgency )


Please check any that relate to your personal life experience.
Emotional History - Confidential Check all that apply.

Thanks for submitting!

© 2020 Thomas Kasperek - Soul Care Ministries    Adapted from Christian Healing Ministries

bottom of page