Pre-Deliverance Form

Pre-Deliverance Form

Before taking the time to fill out this form, it is important that you first contact the ministry to determine if you are a candidate for deliverance. You can connect with the ministry on the 'Contact Us' page of this website. Once deliverance has been determined, in order to prepare the deliverance team for your session, please provide your history in the questionnaire below. All information is strictly confidential and will be viewed only by the individuals involved in personal ministry with you. The way you approach deliverance can determine your victory. It is vital for the success of your deliverance to be honest, transparent and forthcoming while answering the form. The information you provide will expose every legal right or open door the enemy has against you. Without this requested information, the deliverance team will be unsuccessful in driving out demons. Deliverance is not a religious experience, it's a legal exchange. Once the legal rights are broken, your enemy has to release you. Please do not leave out any requested information. Do not hit the back-page button while filling out the form or you can lose all of your information. At the bottom of the form there is a 'save' button if you need to come back to your form later, before submitting.
Name

First Name Last Name
Date

Month Day Year
Date
Phone Number

Area Code Phone Number
Email
example@example.com
Spouses Name

First Name Last Name
Emergency Contact

First Name Last Name
Emergency Phone Number

Area Code Phone Number
How did you hear about this ministry? Did someone refer you?
Best Time To Meet

Weekdays Weeknights Weekends Anytime
Do you have any previous marriages (other than your current)?

Yes No
How many previous marriages?
Are you a Christian (Born-Again)?

Yes No
Age of Christian conversion?
Have you been water baptized?

Yes No
Age of baptism?
Have you been through deliverance prior to this session?

Yes No
Was your prior deliverance successful in driving out demons?

Yes No N/A
What do you think might be the areas of demonic influence in your life? Which demonic spirits are harassing you?
List the top three sins/strongholds you struggle with?
The purpose of this form is to help the deliverance team determine possible entryways for evil spirits. Deliverance is not a religious experience, it's a legal exchange. Our goal is to find the legal right or entry point so your enemy has to release you. The information we obtain from this form should expose all legal rights the enemy has against you.
Generational/ancestral permission as forewarned in Exodus 20:5 is a possibility in anyone's life. There are many ancestors in your history that could have passed a spirit(s) onto you through your bloodline. Likely, you only know about your parents and each of their two parents.
Please give any information that the Holy Spirit brings to mind regarding your ancestors. Examples would be; Involvement with the occult, satanic ceremonies, sexual perversion, incest (sexual abuse/touch by a family member), alcoholism, addiction, depression, suicide, mental disorders, repetitive divorce, adultery, anger, murder, criminal activity, births out of wedlock, involvement in groups such as Wiccan, Freemason, Eastern Star, Rainbow Girls, Fraternity/Sorority, Illuminati, etc.

Note: It is not necessary to give great detail with any of your responses. Ask the Holy Spirit to reveal any area of concern.
Are you aware of your ancestor’s involvement in any of the areas above?

Yes No
If yes, explain.
Select any involvement YOU had with the following (however innocent it seemed at the time).

Ouija Board Dungeon and Dragons (game) Choking game Bloody Mary Magic 8 Ball Games that predict your future Crystal Balls Crystals Charms Incantations Spell books Burning Sage Levitation Seances Satanic Church Alters set up for idol worship Rituals Ceremonies Fortune Tellers Palm Reading Witchdoctors Tarot Cards Voodoo Contacting the dead Interpreting Omens Casting Spells Astroprojecting Mediums Spiritist Hypnosis Hand writing analysis Automatic writing Tea leaves Astrology Horoscopes Books about magic Psychics Seers Divination Sorcery Heavy metal Metallica Sandman Marilyn Manson Halloween Haunted houses Harry Potter books/movies Pokemon cards Pokemon games Enneagram Yoga Chiropractors Eastern medicines Eastern practices Martial Arts Bowing to Sensei (the master in martial arts) Jiu Jitsu Acupuncture Freemason Illuminati The Landmark Forum Catholic worship of Saints Santeria Palo Mayombe Islam Mormonism Jehovah Witness Buddhism Taoism Shamanism Scientology Hinduism New Age Wicca Kabbalah
Please include anything we may have left out in the list above.
Do you have any accursed objects in your home or possession attributed to idolatry, ungodliness, witchcraft or cults? This would include New Age religions; such as books about eastern deities, Buddha statues, jade, crystals, dreamcatchers, essential oils, etc? Native American, African artifacts/jewlery or questionable souvenirs from other countries? Items connected with other religions or rituals such as Renaissance Festival, Wiccan, Freemason, the Koran, Catholic saint statues, Catholic alters (or any other alters), the Rosary, etc? Drugs, pornography, stolen items, vulgar items, horror movies, heavy metal music, skulls, Pokemon cards/games, martial art items, etc? Any witchcraft items like Ouija Board, tarot cards, crystal balls, potions, spell books, incantations, charms, voodoo dolls, burning sage, etc? Or possible items in your house that for some reason seem wrong or a feeling you shouldn't have them?

Yes No
If yes, please list items.
Are you willing to get rid of these items?

Yes No
From birth to early childhood: Are you aware of any trauma you might have experienced during your mother’s pregnancy? Accidents, divorce, spoken words such as, "We shouldn't be having this child" or “We didn’t want a girl, we wanted a boy,” etc.? Please identify and explain.
Are your parents divorced?

Yes No They were never married
If yes, how old were you?
Were there any significant problems in the home, growing up? Explain.
Do you recall any early childhood fears, injuries, nightmares? Do you remember seeing things in your room or feeling an evil presence? Do you recall any encounters of a supernatural kind? Please explain.
Did you have imaginary friends as a child?

Yes No
If yes, what was their names?
Unusual feelings such as; never felt loved, couldn't please my father/mother, feelings of worthlessness, etc.?
Do you recall any spoken words from parents, authority figures or others that were condemning: "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. This includes experiencing an embarrassing or humiliating scenario at school or from a teacher? Explain.
List any lies that you have believed about yourself; Spoken by someone or that you tell yourself.
Ex: "I'am not respected because I don't have a college degree." "I am not a good mom." "You won't be able to run your own business."
Were you exposed to any movies or TV programs that were particularly frightening to you or specific scenes that seem to stick in your memory?
Any physical abuse from parents or others? Please explain.
Did you experience any sexual abuse or sexual embarrassment through childhood? Explain.
Have you been exposed to pornography?

Yes No
If yes, how old were you?
Are you currently watching pornography?

Yes No
Have you engaged in premarital sex?

Yes No
List names of premarital sex partners.
Do you have lustful thoughts?

Yes No
Have you ever engaged in adultery? While married or your partner was married.

Yes No
Participation in sexual immorality including: masturbation, pornography, perversion, indecent exposure, fetishes, dominatrix, BDSM, orgies-(group sex), sexual fantasy, prostitution, topless dancing, Mardi-Gras-(topless), promiscuity, adultery, fornication-(sex outside of marriage), homosexuality, lesbianism, bisexuality, anal sex, bestiality, incest, pedophilia, molestation, rape, etc.?
Have you had an abortion?

Yes No I fathered a child that was aborted
How many abortions?
Do you experience either homosexual, bisexual or lesbian tendencies?

Yes No
Do you experience confusion regarding your gender?

Yes No
If yes, please explain.
Did/do you abuse alcohol, smoke or take drugs? List the drugs.
List any addictions (tobacco, caffeine, alcohol, drugs, shopping, food, prescriptions, gaming, etc.)?
Please list tattoos/location on body.
Participated in college fraternities or sororities?

Yes No
Are you rebellious?

Yes No
Do you struggle submitting to authority?

Yes No
Have you experienced legal trouble?

Yes No
If yes, please explain.
Feelings of guilt and shame?

Yes No
Feelings of hopelessness?

Yes No
Do you feel incredible loneliness?

Yes No
Difficulty in forgiving?

Yes No
If so, will you forgive?

Yes No
List the names of people you want to forgive throughout your lifetime. Include the reason why you should forgive them.
In order to be successful in deliverance, you MUST first forgive others (Matthew 6:14-15).
Do you struggle with forgiving yourself?

Yes No
If yes, please explain.
Do you have difficulty in trusting others?

Yes No
If yes, when did it begin?
Do you struggle with bitterness or resentment?

Yes No
If yes, please explain.
Do you struggle with revenge (an eye for an eye)?

Yes No
Do you experience feelings of self-hate?

Yes No
Have you suffered from self-harm (including cutting yourself)?

Yes No
Do you struggle with suicidal thoughts?

Yes No
Have you attempted suicide?

Yes No
If yes, please explain.
Have you ever felt a supernatural presence in the room?

Yes No
If yes, please explain.
Do you hear voices?

Yes No
If yes, please give example.
Do you experience frequent nightmares?

Yes No
Please list accidents or injuries that were traumatic?
List major surgeries/approximate age. Especially any transplants.
Please list any medical diagnosis you received from a doctor? (Example: diabetes, asthma, hypertension, autoimmune disorder, cancer, heart disease, etc.)
Is there a family history of tuberculosis, diabetes, ulcers, cancer, heart disease, asthma, autoimmune, Autism, ADHD, Dyslexia, Bi-Polar, etc.?
Were you diagnosed with a learning disability?

Yes No
Have you been diagnosed with mentally defined disorders? (Ex: ADHD, Bi-Polar, Dyslexia, Schizophrenia, Aspergers, Autism, etc)?

Yes No
If yes, please list and explain.
Do you experience fatigue without medical reason?

Yes No
Are you often tired, requiring frequent naps?

Yes No
When you read the Bible or try to spend time with God, do you immediately get sleepy and start yawning?

Yes No
Do you suffer from anxiety or panic attacks?

Yes No
Do you experience pain with no medical explanation?

Yes No
If yes, please explain.
Do you experience migraine headaches?

Yes No
Do you struggle with an eating disorder?

Yes No
If yes, when did it begin? Explain.
Do you have a compulsion to restrict certain food groups from diet (meats, dairy, etc)?

Yes No
If yes, please explain.
Do you suffer from sleep disorders?

Yes No
Has there been a death of someone close to you?

Yes No
If yes, whom?
Has grief traumatized you?

Yes No
How long have you suffered from grief?
When attending church, do you experience foul thoughts or mental harassments?

Yes No
Do you have difficulty retaining God’s Word?

Yes No
Do you have difficulty in reading the Bible?

Yes No
Have you experienced anger towards God?

Yes No
Do you have blasphemous thoughts against the Holy Spirit?

Yes No
Do you attribute the work of the Holy Spirit (signs and wonders) to the work of the devil?

Yes No
Do you believe that God no longer speaks personally to his children? That the last words he spoke was written in the bible?

Yes No
Do you believe that supernatural gifts such as speaking in tongues, healing the sick and casting out demons are not for the church today?

Yes No
If yes, please explain.
Are you critical of other Christians who worship God differently than you?

Yes No
Do you often find error in different churches/believers/denominations and feel it is your duty to expose them and warn other people?

Yes No
Do you have a hard time believing that hell/demons/Satan are real?

Yes No
Do you experience unusual fears? Explain.
Do you have an unhealthy fear of death?

Yes No
Do you have a fear of losing your mind?

Yes No
Do you have any extreme phobias (fear of germs, heights, cats, small spaces, reptiles, spiders, etc.)?

Yes No
If yes, name the phobia.
Are you plagued with doubt and unbelief?

Yes No
Do you feel rejected?

Yes No
If yes, please explain.
Do you feel inferior?

Yes No
Do you have thoughts of inadequacy?

Yes No
Do you battle insecurity? (On a scale of 1-10 with 10 being the worst).
Are things seemingly always out of order?

Yes No
Do you feel the need to be in control?

Yes No
Are you a perfectionist?

Yes No
Do you have obsessive thoughts?

Yes No
Do you have compulsive thoughts?

Yes No
Do you often suffer confusion?

Yes No
Do you daydream?

Yes No
Do you lose track of time daily?

Yes No
Is there any behaviors/sins/experiences you believe would be helpful that was not mentioned? Ask the Holy Spirit to bring it to your mind.
Common Symptoms of Demonic Attack

-Common Manifestations
Select common symptoms that applies to you:

A compulsive desire to blaspheme God. Repulsion against the Bible, including a desire to tear or destroy it. Mocking and blasphemous thoughts against the teaching of God’s word. Negative reaction to the name or blood of Jesus. Tremendous apprehension while around a deliverance ministry. Extreme sleepiness when reading the bible or learning about God. Some kind of hindrance blocking the ability to connect with God. Terrifying doubt of one’s salvation after a born-again conversion. Terrifying feelings of guilt even after confessing to God. Inability to believe (even when the person wants to believe). Deep feelings of bitterness and hatred towards others without reason. Compulsive desires to tear others down, even at the expense of lying. Thoughts or behaviors you do not want to think or act out. Desire to do what is right with the inability to carry it out. Constant negative thoughts or images that play in your head. Physical symptoms appearing/leaving suddenly with no explanation. Choking sensations. Body pain/aches that travel around the body with no explanation. Infirmity-physical sickness or disease. Feelings of tightness around the head or eyes. Dizziness, blackouts, or fainting seizures. The feeling of a "black cloud" following you. Deep depression and despair. Compulsive thoughts of suicide. Attempted suicide. Thoughts of self-harm. Cutting yourself (self-harm). Irrational guilt or self-condemnation. Extremely low self-image (unworthy, failure, disgrace). Extreme feelings of hopelessness. Extreme feelings of loneliness. Desires of Isolation. Extreme fatigue Irrational anger or rage. Violent thoughts (suicidal, homicidal, encouraging self-harm). Sudden surges of violent rage, uncontrollable anger, hostility. Thoughts of murder. Attempted murder. Involvement in criminal activity. Nightmares that are reoccurring. Clairvoyant dreams that come true. Horrible nightmares causing intense fear. Seeing demonic images. Insomnia. Frequently wakes up at 3:00am. Mind racing. Sleep paralysis- waking up in a paralyzed state usually accompanied with fear. Experiences sexual orgasim in the middle of sleep. Reoccurring sexual dreams with people other than your spouse. Frequent or uncontrollable yawning. Sleep disorders. Eating disorders. Bulimia. Anorexia. Obesity. Compulsions and obsessions. Extreme nail bitting Panic or fear that grips you regularly. Terrifying and uncontrollable thoughts that seem to come from nowhere. Fascination with the occult. Often confused. Often feels like you live in a fog. Difficulty in remembering things. Inability to make a decision. Extreme disorganization. Hoards-inability to throw things away. Perceptual distortions- perceiving things in others when its not true. Frequent accidents (often indicating a curse). A dark countenance- hollow look around the eyes, contortion of face. Feelings of being watched or sensing an evil presence. Seeing demonic visions while awake. Irrational fears or panic attacks. Hyprochondria-anxiety or obsessions regarding your health. Unhealthy phobias-extreme fear of snakes, heights, water, small spaces, etc.). Sudden personality or attitude change. Multiple personalities. Compulsion to lie, exaggerate or steal. Alcohol or drug abuse (especially with demonic hallucinations). Rebellion and hatred for authority. Compulsion towards vulgar language. Obsession with tattoos. Abnormal or perverted sexual desires. Compulsive sexual sin. Habitual victimization. Irrational evil laughter or crying. Uncontrollable/outlandish behavior like growling, slithering on the floor, animal behavior. Inability to look at others directly in the eye. Speaking an evil language not previously known, a demonic tongue. Demonstration of extraordinary abilities (ESP, telekinesis). Hears voices in the mind that threaten, mock, intimidate, accuse, and bargain. Voices that refer to him/her in the third person. Paranormal activity such as hauntings, objects moving or disappearing. Buzzing in the ear. Inability to speak. Severe headaches. Chills. Heat. Numbness in arms or legs. Temporary paralysis. Twitching. Seizures. Blackouts.
Note: The above checklist has proven to be a good starting place in determining if you should seek deliverance. Experiencing some of these symptoms does not guarantee demonic oppression. Although it's important to note that these are symptoms of people who are under demonic attack and require deliverance.
Sins and Behaviors

Repent and Renounce
Select sins/behaviors you have committed prior and engaged in currently.

Lying Half-Truth Deception Flattery Blasphemy Foul Language Coarse Jokes Mocking Greed Theft Kleptomania Materialism Gossip Slander Arguing Jealousy Envy Competition Pride Ego Arrogance Haughtiness Self-Rightousness Criticism Judgement Fault-Finding Suspicious Skeptical Blame Frustration Resentment Unforgiveness Irritability Intolorance Rage Anger Revenge Retaliation Confrontational Guilt Shame People-Pleasing Compromise Indecision Indifferent Intimidation Inadequecy Daydreaming Fantasy Disorder Procrastination Fatigue Tiredness Laziness Attention-Seeking Unworthiness Insecurity Self-Pity Ineptness Shyness Withdrawn Nervousness Anxiety Fear Fear-of-Man Fear-of-Rejection Fear-of-Failure Worry Paranoia Depression Suicide Insomnia Confussion Forgetfulness Loss-of-Time Unorganized Strife Dissention Division Unbelief Doubt Domination Control Manipulation Witchcraft The Occult Drugs Alcohol Nicotine Caffine Abuse Gluttony Prescription Abuse Rebellion Stubbornness Anti-Submissive Self-Will
Additional comments for the team:
Preparation For Deliverance

Things to consider
In Mark 9:29, the disciples were unable to cast out demons from a young boy. When they asked Jesus why, He replied, “This kind (of demon) can only come out by fasting and praying.” We highly suggest joining the deliverance team in praying and fasting before your session. A possible suggestion is to fast the day before your deliverance. We do not suggest fasting the day of your deliverance unless the Lord prompts you.

It is not uncommon to need multiple sessions in order to be completely free. Evil spirits travel in packs, we have never seen or led a deliverance where only one spirit was present. This is why most people require several sessions. We also cannot guarantee that you will be set free. Your participation, transparency, honesty, and desire for freedom is the key to help us deliver you from demonic oppression. During the session, if you are unwilling in any area that we direct you, the unclean spirits are not necessarily obligated to go.

It is important to understand that when you experience genuine deliverance and evil spirits leave your body; You will immediately feel lighter, your mind will stop racing, your ability to connect with God won't be hindered, your specific manifestations will stop and you will feel like a new person. As wonderful as all that sounds, it is important to put into perspective that deliverance does not mean life will be perfect. Jesus did not promise that and neither do we. Deliverance is like a reset button. You get to face life without the hindrances but sin and temptation are still around the corner. If you open the door, you already know who will come in. Your work does not stop when the evil spirits leave. In fact, it's only beginning. It's important to seek wisdom and discernment on how to maintain your deliverance by keeping the doors closed and every entry point shut. When you have some time, study the scriptures about Mary Magdalene. She was a woman who followed Jesus and had seven demons cast out of her (Luke 8:2). Mary's life wasn't perfect after her deliverance but she served Jesus without hindrance.

Deliverance can take several hours, we suggest you wear comfortable clothes. Ladies, please wear clothing that covers your chest, stomach, and upper legs. Please no skirts or dresses. Our top priority is that you are treated with the utmost respect and dignity.
Love Offerings

There is no set fee for each deliverance session. Love offerings are welcomed. For your convenience, there is a page on this website where you can give.
Liability Release Form

Must be signed before deliverance
For The Brokenhearted Ministries is a biblically-based prayer ministry. It is considered a form of pastoral counseling, not professional counseling. We work with you as you choose to work with us. If you are dealing with serious conditions like physical and mental illness or addiction. Please do not disregard seeking professional help in conjunction with the help you seek through divine healing.

For The Brokenhearted Ministries commits to keeping your personal information concealed. However, this ministry is required by law to report any physical and sexual abuse currently taking place with a minor.
I hereby acknowledge and affirm that all the answers given by myself in response to the questions in this form are voluntarily submitted and the information is true to the best of my knowledge.  I hereby release, indemnify and forever hold harmless For The Brokenhearted Ministries and its agents, staff, employees, and volunteers of any damages, real or perceptual, arising from personal ministry in connection with the information submitted herein.

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*We are not licensed medical professionals: This ministry is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified healthcare providers with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on this form or encountered through this ministry.
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Pre-Deliverance Form

Common Symptoms of Demonic Attack

Sins and Behaviors

Preparation For Deliverance

Love Offerings

Liability Release Form