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Triage form for Spiritual Treatment
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First and Last Name
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ADDRESS:
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Date of Birth:
MM
/
DD
/
YYYY
E-mail:
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Children:
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0
1
2
3
4
5
Wednesday’s Spiritual Treatment
Obsession
Mediumship
Family
Vices
Major Risk
Health
Other:
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Assistance needs
Food
Clothing
Other:
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For Center Staff Only: Public Meeting - Passe 1
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Participation at the Spiritist Center
Study
Charity
Youth
Children's study
Other:
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Wants to implement the Gospel at home?
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Yes
No
Already does it
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