check

Deliverance Request Form

In order for me to provide you with a thorough private deliverance session, please complete the Deliverance Request Form. This will allow me to prepare for our session and formulate a deliverance strategy.

All information that you provide is strictly confidential.

Click the button below to start.

Start

Question 1 of 53

Name (First, Middle, Last):

Question 2 of 53

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

Question 3 of 53

Phone Number (also best time to reach you):

Question 4 of 53

Date of Birth (Month, Date, Year):

Question 5 of 53

Spouses Name (if not married, type NONE):

Question 6 of 53

How many times have you been married?

Question 7 of 53

Names and Ages of Children:

Question 8 of 53

Were you the first born?

A

Yes

B

No

Question 9 of 53

What is your Father's last name?

Question 10 of 53

What is your Mother's maiden name?

Question 11 of 53

Have you accepted Jesus as your personal Lord and Savior?

A

Yes

B

No

C

I Don't Know

Question 12 of 53

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

Question 13 of 53

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...obviously, generational/ancestral permissions 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. It is not necessary to go into detail with any of your responses. Ask the Holy Spirit to show you any area of concern.

Question 15 of 53

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 Masonry, 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 16 of 53

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

Question 17 of 53

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.?

Question 18 of 53

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

Question 19 of 53

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

Question 20 of 53

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 21 of 53

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

Question 22 of 53

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, phychics, seers, Harry Potter books, Pokemon cards, etc.? If Yes, explain:

Question 23 of 53

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

Question 24 of 53

Please list surgeries and approximate age: 

Question 25 of 53

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

Question 26 of 53

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

Question 27 of 53

Have you participated in sex outside of marriage?

A

Yes

B

No

Question 28 of 53

Periods of immorality? If yes, please explain: 

Question 29 of 53

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

Question 30 of 53

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

Question 31 of 53

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

Question 32 of 53

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

Question 33 of 53

Are your parent's divorced? If yes, how old were you?

Question 34 of 53

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

Question 35 of 53

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.

Question 36 of 53

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 37 of 53

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 38 of 53

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

Question 39 of 53

Do you have nightmares? If yes, please explain:

Question 40 of 53

Do you hear voices? If yes, please explain: 

Question 41 of 53

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

Question 42 of 53

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

Question 43 of 53

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

Question 44 of 53

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

Question 45 of 53

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

Question 46 of 53

Do you suffer from sleep disorders?

A

Yes

B

No

Question 47 of 53

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

Question 48 of 53

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

Question 49 of 53

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

Question 50 of 53

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 I 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

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

J

I sometimes fear losing my mind.

K

I have anxiety or panic attacks.

L

I feel incredible loneliness.

M

I struggle with doubt and unbelief.

N

I feel inferior.

O

I have thoughts of inadequacy.

P

I have obsessive thoughts.

Q

I have compulsive thoughts.

R

I have lustful thoughts.

S

I daydream.

T

I am a perfectionist.

U

Things always seem out of order in my life.

V

I feel the need to be in control.

W

I am rebellious.

X

I struggle with or have struggled with pride.

Question 51 of 53

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

Question 52 of 53

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 53 of 53

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?

Confirm and Submit