Request Deliverance

Personal Information

First Name *

Last Name *

Email *

Phone Number *

Street/PO Box + Unit/Apt/Suite (if applicable)

City

State

Zip

Age

Date of Birth

Gender *

Spouse's Name (put None if needed)

Prior Marriages?

Names of children (put None if needed)

Father's Last Name

Mother's Maiden Name

Spiritual Background

Were you the firstborn?

Are you saved?

If saved, where and approximately what age?

Have you been baptized?

Participated in Communion?

Name of current church (put None if needed)

How did you hear about this ministry?

Note: All Ministry sessions are in person only. A representative from our ministry will contact you. The purpose of this form is to help determine possible entry ways for evil spirits. 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.

Ancestral & Early Childhood

Are you aware of ancestor involvement in your life?

Ancestors involved in Freemasonry, Eastern Star, Rainbow Girls, Oddfellows, Rebecca Lodge?

From birth and your early childhood: Trauma during pregnancy by your mom or dad, divorce, words of "We shouldn't be having this child", etc.?

Early childhood fears, injuries, nightmares, see things in your room, felt evil presence?

Any sexual abuse, or sexual embarrassment through childhood?

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?

Any physical abuse from parents or others?

Occult Involvement & Media

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, psychics, seers, Harry Potter books, Pokemon cards, etc.?

Do you have any objects in your home or possession that relate to ungodliness or cults?

Please list accidents or injuries that come to your mind as being frightening to you at the time:

Please list surgeries and approximate age:

Movies or TV programs that were particularly frightening to you, or specific scenes that seem to stick in your memory:

Sexual History & Family

Have you participated in pre-marital sex?

Periods of immorality?

Are your parents divorced?

Exposed to pornography?

Homosexual tendencies?

Sexual dreams?

Participated in college fraternities or sororities?

Abortion?

Lustful Thoughts?

Problems in home?

Emotional & Mental Health

Feelings of guilt and shame?

Hopelessness?

Do you feel incredible loneliness?

Do you feel rejected?

Do you have feelings of gloom?

Do you feel inferior?

Do you have thoughts of inadequacy?

Do you hate yourself?

Have you suffered from self harm?

Have suicidal thoughts?

Diagnosed with depression?

Unusual feelings such as: Never really felt loved, couldn't please my father/mother, feelings of worthlessness, etc.?

Insecurity? (On a scale of 1-10 with 10 being worst)

Has there been a death of someone close to you? If yes, please explain:

Behavioral Patterns & Forgiveness

Drinking and/or drug use?

Do you have any addictions?

Unusual bouts with anger?

Is there bitterness, anger, or unforgiveness?

If so, can you forgive?

Do you have difficulty in forgiving?

Do you have difficulty in trusting others?

Do you daydream?

Are you a perfectionist?

Are things seemingly always out of order?

Do you feel the need to be in control?

Are you rebellious?

Did you have imaginary friends as a child?

Fears & Spiritual Struggles

Do you experience unusual fears?

Do you have a fear of death?

Do you have a fear of losing your mind?

Anxiety or panic attacks?

Are you plagued with doubt and unbelief?

Have you been or are you now angry with God?

Do you have obsessive thoughts?

Compulsive thoughts?

Blasphemous thoughts?

Do you have difficulty reading God's Word?

Difficulty retaining God's Word?

When attending Church do you have "foul" thoughts, jealousies or other mental harassment?

What do you think may be the areas of demonic influence in your life?

Spiritual Experiences

Ever "felt" a presence in the room?

Nightmares?

Voices?

Medical History

Have you been diagnosed by a doctor with any diagnosis of: diabetes, asthma, hypertension, etc.?

Do you have inexplicable pain (no medical explanation)?

Do you have migraine headaches?

Do you feel like you have any eating disorders?

Do you suffer from sleep disorders?

Fatigue without medical reason?

Were you ever diagnosed with a learning disability (A.D.D., etc)?

Blood transfusion?

Any other medically defined disorder?

Is there a history of tuberculosis, diabetes, ulcers, cancer, heart disease, glandular problems, asthma, other, in your family?

Female Health

Pre-menopausal?

In menopause?

Post-menopausal?

PMS difficulties?

Hormone replacement?

Symptoms Assessment

Here are a few symptoms of demonic attack. Please check any symptom that applies to you:

Note: A few symptoms alone may not indicate demonic oppression, but these are common symptoms of demonic attack. When in doubt... cast them out!

Final Comments

Additional Comments:

I understand that this request is confidential and that someone from the ministry team will contact me to discuss next steps.

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