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Deliverance Request Form

In order for me to provide you with a thorough private deliverance session, please complete the Deliverance Request Form. This form is rather long. Please make sure you have adequate time to fill it out as it will need to be done in one sitting. Please do not hit the back button on your browser in the middle of the form as it will not take you to the previous slide but instead will take you out of the form and will not save your responses. Thank you for taking the time to fill out this form; it will allow me to prepare for our session and formulate a deliverance strategy. I look forward to meeting with you soon!

All information that you provide is strictly confidential.

Click the button below to start.

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Question 1 of 52

Name (First, Middle, Last):

Question 2 of 52

Address (Street, City, State, Zip Code, Country):  

Question 3 of 52

Phone Number (also best time to reach you):

Question 4 of 52

Date of Birth (Month, Date, Year):

Question 5 of 52

Spouses Name (if not married, type NONE):

Question 6 of 52

How many times have you been married?

Question 7 of 52

Names and Ages of Children:

Question 8 of 52

Have you accepted Jesus as your personal Lord and Savior?

A

Yes

B

No

C

I Don't Know

Question 9 of 52

What church do you attend?  (If none, type NONE)

Question 10 of 52

How did you find out about me?

Possible Entry Ways of Demons

The purpose of this form is to help determine entry ways for evil spirits...generational/ancestral permissions as forewarned in Exodus 20:5 is a possibility in anyone's life. There are 30 generations of 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.
Ask the Holy Spirit to show you any area of concern.

Question 12 of 52

Please give any information that the Holy Spirit brings to your mind of ancestral curses that might run in the family. 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 the Freemasons, Eastern Star, Rainbow Girls, Oddfellows, Rebecca Lodge, etc.

 

If you are aware of any ancestral involvement, please explain and include what side of the family (mom, dad or both):

Question 13 of 52

Are you aware of any religions your ancestors engaged in? (Catholic Church, Hindu, Islam, Mormon, etc.)

Question 14 of 52

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

Question 15 of 52

Early childhood fears, injuries, nightmares, seeing things in your room, felt evil presence? If yes, explain:

Question 16 of 52

Any sexual abuse or sexual embarrassment through childhood? If yes, explain: 

Question 17 of 52

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? If Yes, explain:

Question 18 of 52

Any physical abuse from parents or others? If Yes, explain:

Question 19 of 52

Involvement (however innocently it may have been) with Ouija Boards, Magic 8 Ball, levitation games, seances, fortune tellers, tarot cards, astrology, horoscopes, New Age, fascination with books about magic, psychics, seers, Harry Potter books, Pokemon cards, etc.? If Yes, explain:

Question 20 of 52

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

Question 21 of 52

Please list surgeries and approximate age: 

Question 22 of 52

Are you taking any medications for physical, mental, or emotional issues? Present or in the past. Please explain:

Question 23 of 52

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

Question 24 of 52

Have you participated in sex with a person you were not married to?

A

Yes

B

No

Question 25 of 52

Periods of immorality? If yes, please explain: 

Question 26 of 52

Drinking or drug use? Smoking or vaping? If yes, please explain:

Question 27 of 52

Do you experience unusual fears? If yes, please explain: 

Question 28 of 52

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

Question 29 of 52

Are there problems in your home? If yes, please explain: 

Question 30 of 52

Are your parent's divorced? If yes, how old were you? How did this impact you?

Question 31 of 52

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

Question 32 of 52

Please check any and all listed below that you have struggled with in the past or currently struggle with. The more transparent you are, the better we can prepare a freedom strategy.

(Select all that apply)
A

I have been exposed to pornography.

B

I have or have had homosexual tendencies.

C

I participated in fraternities or sororities.

D

I have struggled with feelings of guilt and shame.

E

I have struggled with feelings of hopelessness.

F

I often experience fatigue without any medical reason.

G

I have had an abortion.

H

I have difficulty forgiving.

I

If you checked the above box, check this box if you can forgive.

J

I hate myself or have struggled with hating myself.

K

I have and/or currently self-harm.

L

I have feelings of gloom.

M

I feel rejected.

N

I procrastinate.

O

I am a people pleaser.

Question 33 of 52

Unforgiveness will keep you in bondage (Matthew 18:21-35).  Who are some people you need to forgive?  Ask the Holy Spirit to bring them to remembrance.  

Question 34 of 52

Do you have any objects in your home or possession that relate to ungodliness or cults, this would include new age religions, other gods/idols, crystals, artifacts, wiccan, etc.? If yes, please explain:

Question 35 of 52

Have you ever felt a presence in the room? Has it been recently? If yes, please explain:

Question 36 of 52

Do you have nightmares? If yes, please explain:

Question 37 of 52

Do you hear voices? If yes, please explain: 

Question 38 of 52

Have you been diagnosed with any sickness or disease? (diabetes, asthma, hypertension, etc.) If yes, please explain:

Question 39 of 52

Do you have unexplainable pain or symptoms with no medical explanation for it? If yes, please explain:

Question 40 of 52

Do you have difficulty trusting others? If yes, do you know why? Please explain:

Question 41 of 52

Has there been a death of someone close to you? If yes, who? How long ago?

Question 42 of 52

Do you feel like you have an eating disorder? If yes, do you know when it began?  Please explain.

Question 43 of 52

Do you suffer from sleep disorders?

A

Yes

B

No

Question 44 of 52

Do you have any other medically defined disorders? If yes, please explain:

Question 45 of 52

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

Question 46 of 52

Did you have an imaginary friend as a child? If yes, what were their names?

Question 47 of 52

Please check the boxes below indicating current or past struggles. Remember transparency helps me to better prepare for your session.

(Select all that apply)
A

When attending church or other ministries I have "foul" thoughts, jealousies or other mental harassment.

B

I have difficulty reading God's word.

C

I have difficulty retaining God's word.

D

I get migraine headaches.

E

I struggle with addictions.

F

I have been diagnosed with a learning disability.

G

I have a fear of death.

H

I struggle or have struggled with suicidal thoughts.

I

I have attempted to commit suicide.

J

There have been times in my life when I have been angry with God.

K

I sometimes fear losing my mind.

L

I have anxiety or panic attacks.

M

I feel incredible loneliness.

N

I struggle with doubt and unbelief.

O

I feel inferior.

P

I have thoughts of inadequacy.

Q

I have obsessive thoughts.

R

I have compulsive thoughts.

S

I have lustful thoughts.

T

I daydream.

U

I am a perfectionist.

V

Things always seem out of order in my life.

W

I feel the need to be in control.

X

I am rebellious.

Y

I struggle with or have struggled with pride.

Question 48 of 52

Do you struggle with insecurity? On a scale of 1-10 with 10 being the worst, what number would you be? Please explain:

Question 49 of 52

Below are a few symptoms of demonic attack, please check any symptoms that apply to you:

(Select all that apply)
A

A compulsive desire to blaspheme God

B

A revulsion against the Bible, including a desire to tear it up and destroy it

C

Compulsive thoughts of suicide or murder

D

Deep feelings of bitterness and hatred toward others without reason: Jews, other races, the church, strong Christian leaders

E

Any compulsive temptations which seek to force you to thoughts or behavior which you truly do not want to do or think

F

Compulsive desires to tear other people down, even if it means lying to do so. Vicious cutting by the tongue.

G

Terrifying feelings of guilt even after honest confession is made to the Lord.

H

Certain physical symptoms which may appear suddenly or leave quickly and there are no physical or physiological reason.

I

Pains which seem to move around and for which there is no medical cause

J

Feelings of tightness about the head or eyes

K

Dizziness, blackouts, or fainting seizures

L

Sudden surges of violent rage, uncontrollable anger, or seething feelings of hostility

M

Terrifying doubt of one's salvation even though they once knew the joy of salvation

N

Seizures of panic or other fear that is terrifying

O

Dreams or nightmares that are of a horrific nature and often recurring.

P

Abnormal or perverted sexual desires.

Q

Questions and challenges to God's Word.

R

compulsions and obsessions

S

Rebellion and hatred for authority.

T

Bizarre terrifying thoughts that seem to come from nowhere and you cannot control them.

U

Fascination with the occult.

V

Involvement in criminal activity.

W

Extremely low self-image (unworthy, a failure, no good - a constant undermining of the self-identity)

X

Constant confusion in thinking (sometimes great difficulty in remembering things).

Y

Inability to believe (even when the person wants to).

Z

Mocking and blasphemous thoughts against preaching/teaching of the Word of God.

AA

Perceptual distortions - perceiving anger, hostility, in others when it doesn't really exist - seeing only judgment in the scriptures.

AB

Deep depression and despondency (frequently and at significant times)

AC

Horrible nightmares causing fear (often having demonic images).

AD

Violent thoughts (suicidal, homicidal, encouraging self-abuse, etc.).

AE

Hatred and bitterness toward others for no justifiable reason.

AF

Tremendous hostility or fear when encountering someone involved in deliverance work.

AG

Feelings of being watched or sensing an evil presence.

AH

Irrational fears - panic attacks - phobias.

AI

Irrational anger - rage.

AJ

Irrational guilt - self-condemnation to the extreme.

AK

Desire to do what is right (inability to carry it out).

AL

Sudden personality and attitude changes (severe contrasts - appears schizophrenic) Bi-polar disorder.

AM

A strong aversion toward scripture reading and prayer (especially one on one).

AN

A dark countenance (steely or hollow look in eyes - contraction of the pupils - sometimes facial features contort or change - often an inability to look at your directly.

AO

Lying, exaggerating, or stealing compulsively (often wondering why).

AP

Drug abuse (especially when there is demonic hallucinations).

AQ

Eating obsessions - bulimia, anorexia nervosa.

AR

Compulsive sexual sins (especially perversions).

AS

Irrational laughter or crying.

AT

Irrational violence - compulsion to hurt self and/or someone else.

AU

Sudden speaking of a language not previously known (often an ethnic language of ancestors).

AV

Reactions to the name and blood of Jesus Christ (verbally or through body language).

AW

Extreme restlessness (especially in a spiritual environment).

AX

Uncontrollable cutting and mocking tongue.

AY

Vulgar language and actions.

AZ

Loss of time (from minutes to hours - ending up someplace, not knowing how you got there - regularly doing things of which there is no memory).

BA

Extreme sleepiness around spiritual things.

BB

Demonstration of extraordinary abilities (either ESP or Telekinesis).

BC

Voices are heard in the mind (they mock, intimidate, accuse, threaten or bargain).

BD

Voice - refers to him/her in the third person.

BE

Supernatural experiences - hauntings, movement or disappearance of objects, and other strange manifestations.

BF

Seizures (too long and/or too regular).

BG

Pain (without justifiable explanation - especially in head and/or stomach).

BH

Blackouts.

BI

Physical ailments can often be alleviated immediately by a command of spiritual authority (i.e. epileptic seizure, asthma attacks, various pains).

BJ

Sudden interference with bodily functions (temporary) - buzzing in ears, inability to speak or hear, sudden severe headache, hypersensitivity in hearing or touch, sudden chills or overwhelming heat in body, numbness in arms or legs, temporary paralysis.

Question 50 of 52

A few symptoms may not indicate demonic oppression, but these are very common symptoms for those under demonic attack.  

 

Are there any additional comments that would help us prepare?  Any other "issues" in your life? Abnormal things in your life that seem to only occur to you or around you? Things other people say about you even if you don't believe them or notice it?

Question 51 of 52

The first deliverance session is scheduled in a 4 hour block. Some can be take less time; some can take more time. Some people only need one session. Some people need multiple sessions. We can discuss this on an introductory call. 

 

My office is located in Norman, Oklahoma. Periodically, I will schedule sessions in Garland, TX to accommodate Dallas/Ft. Worth clients. Session can also be done via phone or video chat. 

 

Please mark your availability and preferences below. 

(Select all that apply)
A

Weekday mornings

B

Weekday afternoons

C

Weekday evenings

D

Saturdays

E

I can be available anytime.

F

I want to do a phone session.

G

I want to come to your Oklahoma office.

H

I want to know when you will be in Garland, TX next.

Question 52 of 52

Any additional comments you would like to add about your availability for scheduling a session?

Confirm and Submit