Background Information

What is your age?

Gender

What is your occupation?

What is your home address?

Primary Prayer Needs

• Deliverance

• Inner Healing

• Physical Healing

If referred, please provide the referrer's name

Are you single, married, divorced, or widowed?

If divorced, how many times?

How many children do you have and what are their ages?

Are you a Christian?

Have you accepted Jesus Christ as your Lord and Savior?

Have you been baptized?

Do you read the Bible regularly?

Current church attendance

Denomination or church affiliation

What religion are your parents?

Are you adopted?

Were you conceived before your parents were married?

On a scale of 1-10, how is your current relationship with God?

Are there any sins or regrets that need confession?

How is your relationship with your father?

How is your relationship with your mother?

Do you have any step parents?

If yes, how is your relationship with your stepfather? (otherwise skip)

If yes, how is your relationship with your stepmother? (otherwise skip)

Have you had previous deliverance or exorcism?

If yes, with who and what ministry?

If yes, when was your last session?

Have you had previous inner healing?

If yes, with who and what ministry?

If yes, when was your last session?

Have you had previous physical healing?

If yes, with who and what ministry?

When was your last session?

Non-Christian Practices

Please check any non-Christian practices (past or present)

• Atheism/Agnostic

• Buddhism/Zen

• Dianetics (Scientology)

• Freemasonry (to include family members)

• Hinduism

• Islam/Koran

• Jehovah's Witness

• Kabbalah

• Mormonism

• Santeria

• Satanism

• Voodoo

• Witchcraft

• N/A

• Other (not listed)

If Other, please explain (otherwise skip)

Emotional and Mental Health

Please check any emotional health issues (past or present)

• Anger

• Bitterness

• Emotional Abuse

• Hatred

• Physical Abuser

• Physical Abuse Victim

• Rage

• Revenge

• N/A

• Other (not listed)

If Other, please explain (otherwise skip)

Are you currently on medication for mental health?

Are you under the care of a psychologist/psychiatrist?

Please check any mental health issues (past or present)

• ADD/ADHD

• Anxiety/Panic

• Bipolar

• Depression

• Fear

• Insecurity

• Low Self Esteem

• MPD/DID

• OCD

• Schizophrenia

• Self Condemnation

• Worthlessness

• N/A

• Other (not listed)

If Other, please explain (otherwise skip)

Have you ever attempted or considered suicide?

If Yes, how many attempts?

Have you ever had an abortion (as the woman or the partner)?

If Yes, please explain

Please list any instances of verbal or physical abuse you have experienced, including the approximate age at which each incident occurred

Please list any individuals or entities (e.g., God, yourself, family members, ex-partners, organizations, or others) toward whom you still feel resentment, bitterness, or strong negative emotions due to verbal or physical abuse

Addictions and Criminal History

Please check any addictions or habits (past or present)

• Alcoholism

• Drugs

• Food / Eating Disorders

• Gambling

• Gaming

• Prescription Drugs

• Sex

• Sleep Aids

• Tobacco

• Workaholism

• N/A

• Other (not listed)

If Other, please explain (otherwise skip)

Please check any criminal history

• Arrested/Imprisoned

• Rape

• Selling Illegal Drugs

• Vandalism

• Violent Acts

• Other

If Other, please explain (otherwise skip)

Occult and New Age

Please check any Occult and New Age (past or present)

• Acupuncture

• Astral Projection

• Astrology/Horoscopes

• Automatic Writing

• Blood oaths/covenants

• Channeling

• Crystals

• Fire walking

• Fortune Telling

• Levitation

• Ouija Board

• Past Life Therapy

• Psychic Consultation

• Reiki

• Seances

• Spells

• Spiritual baths or cleansing

• Tattoos with occult symbols or death

• Tarot Cards

• Transcendental Meditation

• Voodoo

• Witchcraft

• Yoga

• N/A

• Other (not listed)

If Other, please explain (otherwise skip)

Has anyone dedicated you (or your family) to spiritual entities?

Do you have any objects in your possession related to the occult?

If yes, what are they? (otherwise skip)

Has anyone in your family (parents, siblings, ancestors) been involved in witchcraft?

If yes, please list their names and your relationship to each

Sexual Sins and Abuse

Please check any sexual sins (past or present)

• Adultery

• Bestiality

• Cross Dressing

• Internet/Phone Sex

• Lustful Thoughts

• Molestation

• Necrophilia (sex with a corpse)

• Perverted Sex

• Pornography

• Promiscuity

• Prostitution

• Raped

• Sadomasochism

• Strip Clubs

• N/A

• Other (not listed)

If Other, please explain (otherwise skip)

Please list any instances of sexual abuse you have experienced, including the approximate age at which each incident occurred

Please list any individuals or entities (e.g., God, yourself, family members, ex-partners, organizations, or others) toward whom you still feel resentment, bitterness, or strong negative emotions due to sexual abuse

Demonic Behavior

Please check if you experienced any demonic behavior (past or present)

• Anti-Christ Obsessions

• Curses Placed on You or Your Family

• Hearing Voices

• Worship of Satan or Demons

• Desire to Curse God or Christ

• See Shadows or Orbs or Ghosts

• Smell Strange Odors

• Sex with a Demon

• N/A

• Other (not listed)

If Other, please explain (otherwise skip)

Have you experienced lost time?

Have you experienced sleep paralysis?

Generational and Family Issues

Generational and family issues (parents, grandparents, siblings, uncles/aunts)

• Psychological issues (depression / anxiety / schizophrenia)

• Addictive disorders (substance abuse / eating disorders / gambling / spending / workaholism / sexual addiction)

• Beliefs and emotions (inferiority / shame / anger / violence / fear / hatred of men or women)

• Relational brokenness (inability to be alone / people pleasing / neglect / abandonment / divorce / abuse)

• Sexual brokenness (promiscuity / pornography / infidelity)

• Inherited sickness and diseases (heart / cancer / strokes)

• Unnatural death (stillborn children / miscarriage / abortion / untimely or violent death / suicide)

• Accidents / mishaps / disasters

• Inability to thrive or prosper (repeated financial problems)

• Spiritual patterns (occult / idolatry / spiritual blindness / religiosity)

• N/A

• Other

If Other, please explain (otherwise skip)

Prayer for Physical Healing

If requesting prayer for physical healing, please check all that apply

• Chronic back/neck/sciatic pain

• Migraines or chronic headaches

• Arthritis or joint pain

• Fibromyalgia or widespread pain

• Cancer

• Digestive issues (Chrohn’s/IBS/colitis/reflux)

• Thyroid problems

• Chronic fatigue/ Long-COVID / anti-viral

• Infertility or recurrent miscarriage

• Autoimmune disease (lupus / MS / psoriasis)

• Heart issues (high BP / arrhythmia)

• Neurological (Parkinson’s / neuropathy / tremors)

• Type 2 diabetes or blood sugar issues

• Server allergies / histamine / mast-cell issues

• Eyesight (macular degeneration / cataracts / glaucoma)

• Other (not listed)

If Other, please explain (otherwise skip)

When did these physical ailments start?

Anticipated Outcome and Final Thoughts

On a scale of 1-10, how much do you expect to be completely free and healed by the end of this session?

Provide any additional details that are important and not already covered