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Name *

First

Last

Date *

First

Middle

Last

Gender *

Male
Female

Age *

Marital Status *

Nationality *

Occupation *

Phone *

Email

Residential Address *

Town/City *

Region/County *

Country/State *

Religion *

Name of Local Church *

Are You Born Again? *

Yes
No

Do you have any sickness? *

Yes
No

If Yes, please specify

Please state the nature of your problem you want us to help you with *

For how long have you been experiencing this problem? *

Any other detail you would want us to know with regards to your problem

(Hospitalization, Medication, Challenges etc.)

Have you had counselling before? *

Yes
No

If Yes, where and when?

How did you hear of Salvation Clinic International Ministries *

Do you intend to come alone or accompanied? (If you will be accompanied, please ask each of those with you to also submit this form, indicating in the comments section that they intend to come with you) *

Yes
No

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