Questionnaire

Address *

Main Phone Number *

City *

Cell Phone Number *

State and Zip code *

Have you experienced deliverance ministry before? *

Note: If you have received or experienced deliverance, you can use the box to the right for comments.

Comment *

To answer the questions below please select all that apply and fill in the blanks as honestly as possible.

Marital Status *

Spouse's name *

How many times have you been married? *

Are you currently the victim in an abusive relationship? *

Spiritual Status: Are you a “born again” Christian? *

Do you have assurance of your salvation? *

Do you have your prayer language? *

When were you born again *

Have you been baptized? *

Are you experiencing difficulty with Bible study, prayer, worship or spiritual gifts? Please describe concerns. *

Are you ready to be set free and change any habits that are related to your circumstances? *

Are you ready to forgive those who hurt you and repent of your sins? *

Personal Status: Have you been previously diagnosed by a professional counselor? *

If yes, what was the diagnosis? *

Do you use either prescription or non-prescription drugs to help you sleep? *

List any current prescription medication and health concerns: *

Have you ever had a nervous breakdown? *

If Yes, When? *

Do you suffer from panic or anxiety attacks? *

If Yes, when? *

Are you easily angered? *

Are you easily offended? *

Do you feel rejected often? *

Is it difficult for you to forgive? *

Do you have problems making decisions and staying with your decision? *

Do you have any difficulty remembering the first ten years of your life? *

Have you ever been injured in an automobile or other vehicle accident? *

Have you ever heard voices from the inside, especially under stress? *

Does your handwriting change or go from printing to cursive? *

Describe any large memory gaps: *

Describe any emotional traumas that placed you in survival mode: *

Family of Origin

Where were you raised? *

Where were you in birth order? *

How many siblings did you have? *

Describe any issues with siblings *

Describe your relationship with your father. *

Describe your relationship with your mother. *

To your knowledge, did you experience molestation, incest or inappropriate touch as a child? *

Who hurt you? *

Have you ever been subjected to occult ritual abuse? *

Select all that apply to you *

Schizophrenia Bipolar Disorder Depression MPD/DID

Did your parents lean on you for support? *

Did your parents wish you were of the opposite sex? *

On a scale from 1-10 was your childhood home cold and unloving or warm and very loving? been 1 Cold/Unloving and 10 Warm Loving *

Are there any family members you don’t feel loved by? *

Describe: *

Have you viewed X-Rated movies or pornography? *

Involved in prostitution? *

Family Heritage

Were your ancestors of European royal descent? *

Do you have American Indian ancestors? *

Were Gypsies in the family? *

Please describe your family lineage *

Does your name have any particular significance as to family tradition or cultural/national heritage? *

What religion did your parents practice? *

To your knowledge, have your parents, grandparents or great-grandparents ever been involved in any cult, occult, New Age or non-Christian religious practices? *

Grandparents? *

Personal Spiritual Inventory

What spiritual experiences have you had that would be considered out of the ordinary? *

Do you regularly wake up at 12:00 or 3:00? *

Have you ever felt you have had sex with a demon (incubus or succubus)? *

Have you ever had choking sensations or pains which seem to move and for which there is no medical cause? Explain *

Describe any occult participation, including childhood games *

Have you been inside a Buddhist or Mormon temple or any type of Lodge or secret society? *

Have you had treatment from alternative medicine providers? *

If yes, please describe: *

Are the experiences you had in the military causing nightmares or problems for you today? *

Specifically which issue would you like to begin addressing at your first meeting? *

In order of priority what other issues do you wish to address: *

Please list any questions or concerns you would like to address before ministry begins. *

Ministry Questionnaire

Questionnaire *This information is private/confidential and will not be used for any other purpose.

Family of Origin

Family Heritage

Personal Spiritual Inventory