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First Name
Last Name
Email
Phone Number
What is the nature of your struggle?
Marriage Counseling
Alcohol
Individual Counseling
Smoking
Deliverance & Prayer
Drugs
Gambling
Overeating
Shopping
Abstinence, deprivation, anorexia, bulimia
Family Help
How long has this struggle been?
Do you have a commitment to Chrisitianity/church?
Yes
No
Occasionally
I was hurt in church before and am not sure I trust church.
Who is walking with you through this struggle?
How have you already tried to get free of this?
Who is being hurt by this issue?
Wife
Children
Job
My future
The public
Only me
Other
What are your fears?
Date Input
Month
January
February
March
April
May
June
July
August
September
October
November
December
Date
1
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10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
1912
1913
1914
1915
1916
1917
1918
1919
1920
1921
1922
1923
1924
1925
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
Year
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
2043
2044
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