Today's Date:
Name (First, Middle, Last)
Email
Address (Street Address, City, State, Zip):
Phone Number:
Date of Birth:
Spouse's Name (put NONE if not married):
If previously married, how many times?
Names of Children with Ages:
Father's Last Name:
Mother's Maiden Name:
Possible Entry Ways
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.
Please give any information that the Holy Spirit brings to your mind. 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:
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? If yes, explain:
Any sexual abuse, or sexual embarrassment through childhood? If yes, explain:
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:
Any physical abuse from parents or others? If Yes, explain:
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, physics seers, Harry Potter books, Pokemon cards, etc.? If Yes, explain:
Please list accidents or injuries that come to your mind as being frightening to you at the time:
Please list surgeries and approximate age:
Are you taking any medications for any physical, mental, or emotional issues? Please explain:
Movies or TV programs that were particularly frightening to you, or specific scenes that seem to stick in your memory:
Periods of immorality? If yes, please explain:
Drinking or drug use? If yes, please explain:
Do you experience unusual fears? If yes, please explain:
What do you think may be the areas of demonic influence in your life?
Are your parent's divorced? If yes, how old were you?
Unusual feelings such as : Never really felt loved, couldn't please my father/mother, feelings of worthlessness? If yes, please explain:
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:
Have you ever felt a presence in the room? Has it been recently? If yes, please explain:
Do you have nightmares? If yes, please explain:
Do you hear voices? If yes, please explain:
Have you been diagnosed with any sickness or disease? (diabetes, asthma, hypertension, etc) If yes, please explain:
Do you have unexplainable pain or symptoms with no medical explanation for it? If yes, please explain:
Do you have difficulty trusting others? If yes, go you know why? Please explain:
Has there been a death of someone close to you? If yes, who?
Do you feel like you have an eating disorder? If yes, do you know when it began? Please give approximate height and weight.
Do you suffer from sleep disorders? If yes, please explain:
Do you have any other medically defined disorders? If yes, please explain:
Is there a history of tuberculosis, diabetes, ulcers, cancer, heart disease, glandular problems, asthma, other in your family? If yes, please explain:
Did you have an imaginary friend as a child? If yes, what were their names?
Do you struggle with insecurity? On a scale of 1-10 with 10 being the worst, what number would you be? Please explain:
Below are a few symptoms of demonic attack, please check any symptoms that apply to you:
A compulsive desire to blaspheme God A revulsion against the Bible, including a desire to tear it up and destroy it Compulsive thoughts of suicide or murder Deep feelings of bitterness and hatred toward others without reason: Jews, other races, the church, strong Christian leaders Any compulsive temptations which seek to force you to thoughts or behavior which you truly do not want to do or think Compulsive desires to tear other people down, even if it means lying to do so. Vicious cutting by the tongue. Terrifying feelings of guilt even after honest confession is made to the Lord. Certain physical symptoms which may appear suddenly or leave quickly and there are no physical or physiological reason. Pains which seem to move around and for which there is no medical cause Feelings of tightness about the head or eyes Dizziness, blackouts, or fainting seizures Deep depression and despondency Sudden surges of violent rage, uncontrollable anger, or seething feelings of hostility Terrifying doubt of one's salvation even though they once knew the joy of salvation Seizures of panic or other fear that is terrifying Dreams or nightmares that are of a horrific nature and often ...recurring. Clairvoyant dreams that may even come true are most often demonic. Abnormal or perverted sexual desires. Questions and challenges to God's Word. Sleep or eating disorders without physical cause. Most compulsions and obsessions. Rebellion and hatred for authority. Bizarre terrifying thoughts that seem to come from nowhere and you cannot control them. Fascination with the occult. Involvement in criminal activity. Extremely low self-image (unworthy, a failure, no good - a constant undermining of the self-identity) Constant confusion in thinking (sometimes great difficulty in remembering things). Inability to believe (even when the person wants to). Mocking and blasphemous thoughts against preaching/teaching of the Word of God. Perceptual distortions - perceiving anger, hostility, in others when it doesn't really exist - seeing only judgment in the scriptures. Horrible nightmares causing fear (often having demonic images). Violent thoughts (suicidal, homicidal, encouraging self-abuse, etc.). Hatred and bitterness toward others for no justifiable reason. Tremendous hostility or fear when encountering someone involved in deliverance work. Feelings of being watched or sensing an evil presence. Deep depression and despondency (frequently and at significant times). Irrational fears - panic attacks - phobias. Irrational anger - rage. Irrational guilt - self-condemnation to the extreme. Desire to do what is right (inability to carry it out). Sudden personality and attitude changes (severe contrasts - appears schizophrenic) Bi-polar disorder. A strong aversion toward scripture reading and prayer (especially one on one). 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. Lying, exaggerating, or stealing compulsively (often wondering why). Drug abuse (especially when there is demonic hallucinations). Eating obsessions - bulimia, anorexia nervosa. Compulsive sexual sins (especially perversions). Irrational laughter or crying. Irrational violence - compulsion to hurt self and/or someone else. Sudden speaking of a language not previously known (often an ethnic language of ancestors). Reactions to the name and blood of Jesus Christ (verbally or through body language). Extreme restlessness (especially in a spiritual environment). Uncontrollable cutting and mocking tongue. Vulgar language and actions. 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). Extreme sleepiness around spiritual things. Demonstration of extraordinary abilities (either ESP or Telekinesis). Voices are heard in the mind (they mock, intimidate, accuse, threaten or bargain). Voice - refers to him/her in the third person. Supernatural experiences - hauntings, movement or disappearance of objects, and other strange manifestations. Seizures (too long and/or too regular). Pain (without justifiable explanation - especially in head and/or stomach). Blackouts. Physical ailments can often be alleviated immediately by a command of spiritual authority (i.e. epileptic seizure, asthma attacks, various pains). 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.
A few symptoms may not indicate demonic oppression, but these are very common symptoms for those under demonic attack. After all there is really nothing to lose by going through deliverance except maybe one's pride. When it doubt, cast them out! Are there any additional comments that would help us prepare?
Before Coming For Deliverance
There is something you can do to help bring about your freedom. I recommend that you deal with these issues before coming for deliverance.
In order for the deliverance to be successful there can be NO unforgiveness in your life. Unforgiveness is legal permission for demons to torment believers: Matthew 18:23-35. Do not neglect the area of forgiveness for yourself. You must also forgive yourself in order to be free. A typical prayer might be as follows:
"Father, because You have forgiven me I choose to forgive others, everyone who has hurt me, lied to me or disappointed me, I forgive. I confess unforgiveness as sin and repent of it. I receive Your forgiveness and apply it my life by forgiving myself. Thank You for Your grace and mercy in Jesus Name. Amen."
If there was ever any involvement (however innocent), in Satanic activities, witchcraft, cults or occultic activities they must be renounced. Typical prayer:
"Father, I denounce any bond, or agreement I ever made with Satan and the kingdom of darkness. I know there can be no valid contract with a liar and I renounce any words, oaths or pledges made to Satan and I choose to be totally free from them. I choose to be cleansed from any ties with Satan in Jesus Name. Amen."
Sexual relationships outside of marriage...are called "Soul Ties" and each one could be an entry point for demon spirits. The ties must be broken by confessing them as sin and choosing to be free from them. I will include a prayer you can pray. It would be best if you could do so by denouncing each one by name, do the best you can with that. The deliverance process involves canceling permission of evil spirits to be in our life. This prayer and renunciation will cancel consent that was granted through soul ties. The prayer can be something like this:
"Father, I confess the sin of sexual relations outside of marriage. I renounce that sinful activity in Jesus' Name. I call back that part of me that was given to another, and I refuse that part of another that may have come to me. I denounce soul ties with and choose to be free in Jesus Christ' Name. Amen"
What Now?
Our deliverance team will review your request form to determine if you are a candidate for deliverance. Please be expecting a call from our ministry team to schedule a time to meet. We are currently meeting in Garland, TX and Bedford, TX for deliverance ministry.
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