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// DELIVERANCE INTAKE
PREREQ'S
DID YOU COMPLETE THE reCAPTCHA AT THE END OF SUBMITTING YOUR FORM? SCROLL UP AND DOWN TO DO SO.
INTAKE
DELIVERANCE INTAKE
Please fill of the Pre-Deliverance History form to prepare the deliverance team for their session with you. Write “N/A” (Not Applicable) in any area that does not apply to you. Please use additional paper if required and record the Question Number with your answer. Please sign the Liability Release at the bottom of the form. All information that you provide is strictly confidential and will be viewed only by the individual(s) involved in personal ministry with you.
YOUR FULL NAME
YOUR SPOUSE NAME
Email
Phone
TODAY'S DATE
Address
Birthday
Prior marriages?
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If yes, how many?
Names of Children?
Were you the first born?
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Are you a born again Bible believing christian?
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Are you filled with the Holyspirit?
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At what age?
What is the makeup of your spiritual experience? check all that apply if any?
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Please explain if you did not see yours.
The purpose of this form is to help determine possible entryways for evil spirits...obviously, generational/ancestral permission as forewarned in Exodus 20:5 is a possibility in anyone's life. There are 30 ancestors in your history that could have passed a spirit on to you, likely, you only know about your parents and each of their two parents.Please give any information that the Holy Spirit brings to your mind. Examples would be involvement with the occult, sexual perversion, alcoholism, depression or mental disorders, lots of divorce, adultery, anger, criminal activity, births out of wedlock, involvement in groups such as Masonry, Eastern Star, Rainbow Girls, Oddfellows and Rebecca Lodge, secret societies etc. I acknowledge this and want to continue.
Are you aware of ancestor involvement in any of the previously listed?
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Do you recall any early childhood fears, injuries, nightmares? Do you remember seeing things in your room or feeling an evil presence? Do you recall any encounters of a supernatural kind?
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Any physical abuse from parents or others?
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Note: It is NOT necessary to go into great detail with any of your responses. Ask the Holy Spirit to show you any area of concern. I acknowledge and wish to continue
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From birth and your early childhood: Are you aware of any trauma you might have experienced during your mother’s pregnancy? Accidents, divorce, spoken words such as "We shouldn't be having this child", etc.?
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If yes, Explain
Involvement (however innocently it may have been) with Ouija Boards, Magic 8 Ball, levitation games, seances, fortune tellers, tarot cards, astrology, horoscopes, fascination with books about magic, physics seers, etc.?
Choose an option
Do you recall any spoken words from parents, or others that were condemnation: "You're fat, you're stupid, you'll never amount to anything, you always mess up, I don't know why we had you. You can't be in our group, etc embarrassing or humiliating experiences at school or from school teacher?
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Periods of, or habitual immorality? (including pornography, sexual fantasy,promiscuity, etc.) Explain below, please.
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Drinking and/or drug use? Explain please.
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Are you often fed during your sleep and/or dreams?
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If so explain, please.
Do things appear before you that others do not see, but it is frightening? if yes explain.
Do you hear spirits talking to you and/or accusing, fussing, and/or threatening you? If yes, explain
Are (or were) there any significant problems in the home growing up? If yes, explain.
Are your parents divorced? If yes, how old were you when this happened?
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Homosexual tendencies?
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Participated in college fraternities or sororities?
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Participated in college fraternities or sororities?
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Feelings of guilt and shame?
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Hopelessness?
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Is there anyone or an organization you struggle to forgive? If yes, please explain
Have you ever "felt" a presence in the room? If yes, explain if possible.
Do you have nightmares OFTEN?
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Have you been diagnosed by a doctor as having: (list any diagnosis, diabetes, asthma hypertension, etc.)
Do you have any objects in your home or possession that relate to ungodliness or cults, this would include new age religions, such as books about eastern deities, crystals, heavy metal music, Emo music, Secular music, Native American/African artifacts, Items connected with other religions or rituals, Wiccan or other occult items, etc.? If yes, explain.
Do you have these symptoms? Check all that apply if any.
A compulsive desire to blaspheme God. (Hate toward Jesus and/or the Bible).
Compulsive thoughts of suicide or murder.
Deep feelings of bitterness and hatred toward others without reason: Jews
Any compulsive temptations
Compulsive desires to tear other people down
Terrifying feelings of guilt even after honest confession is made to the Lord.
Certain physical symptoms which may appear suddenly or leave quickly and there are no physical or physiological reason.
Choking sensations.
Pains that seem to move around and for which there is no medical cause.
Dizziness
Feelings of tightness about the head or eyes.
Terrifying doubt of one's salvation even though they once knew the joy of salvation.
Dreams or nightmares that are of a horrific nature and often recurring. Clairvoyant dreams that may even come true are most often demonic.
Abnormal or perverted sexual desires.
Sleep or eating disorders without physical cause.
Rebellion and hatred for authority.
Bizarre terrifying thoughts that seem to come from nowhere and you cannot control them.
Extremely low self-image (unworthy
Irrational fears - panic attacks - phobias.
A dark countenance (steely or hollow look in eyes - contraction/dilation of the pupils - sometimes facial features contort or change - often an inability to look at others directly
Irrational laughter or crying.
Extreme restlessness (especially in a spiritual environment)
Uncontrollable cutting and mocking tongue.
Loss of time (from minutes to hours - ending up someplace
Supernatural experiences - hauntings
Seizures (too long and/or too regular).
Sudden interference with bodily functions (temporary) - buzzing in ears
Can speak in an unknown language at times
None of The Above
Do you have inexplicable pain...no medical explanation for it? If yes explain please.
Do you have difficulty in trusting others?
Choose an option
What made you decide, “right now”, you must be free?
Who is you apostle, pastor, leader and where do you attend church and/or have assembly?
Do you need a guardian present which is? Please explain.
TODAY'S DATE
Your Signature
Clear
Are you currently on any medication and/or receiving mental health services? If yes, please explain.
This form was completed within my own free will. I was sober, and able to make an informed decision.
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Apply
Thank you! We’ll be in touch.
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