Pre-Deliverance Form

PRE-DELIVERANCE FORM
For The Brokenhearted Ministry specializes in deep, deep deliverance. There will be no stone left unturned and everything will be brought to the surface. Your deliverance journey could require 1-2 sessions. We recommend that if you have undergone mass (group) deliverance at an altar, it is important to seek deeper deliverance to uproot what was left. The Bible says, "The truth will set you free" (John 8:31). So coupled with your deliverance, we will also equip you with biblical understanding to receive and maintain your freedom. To begin the process and prepare the deliverance team for your session, please provide your history in the questionnaire below. All information is strictly confidential and will only be discussed by the ministry team. 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. 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.

We suggest using a device larger than your phone to complete this form, but it is not necessary. 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 it.
DELIVERANCE HOURS
Tuesday thru Friday

11:30am- 5:00pm

* With the current demand for deliverance, we are booking several weeks in advance.
PERSONAL INFORMATION
Name*

First NameLast Name
Today's Date*

MonthDayYear
Date
Gender*
Age*
You must be 18 or older to receive deliverance
CELL Number (only)*

Area CodePhone Number
Email*
example@example.com
What city and state do you live in?*
Spouse Name

First NameLast Name
How did you hear about this ministry? Who referred you? Be specific*
Occupation?
What type of work are you involved in
Do you have any previous marriages (other than your current)?

YesNo
How many previous marriages?
Provide the first name of previous spouse(s).
Are you pregnant? (Yes, we will perform deliverance on women who are pregnant up through 7 months).

YesNo
How many months pregnant?
Are you a Christian (Born-Again)?*

YesNo
Age of Christian conversion?
Have you been water baptized by your own choice (not as a baby)?

YesNo
Age of baptism?
Do you speak in tongues through the Holy Spirit?

YesNo
Have you been through deliverance prior to this session?

YesNo
Was your prior deliverance successful in driving out demons?

YesNoN/A
Which demonic spirits do you need deliverance from?*
List the top three sins you struggle with?*
BEFORE YOU START
We offer zoom (online) deliverance sessions. We conduct zoom deliverance all over the world and have never experienced an unsuccessful deliverance due to utilizing the internet. Zoom is convenient and offers you the privacy of your own house without having to drive home (exhausted) after your deliverance. We ask that you are in an area with zero distraction during your session. Our Care Team will send you a zoom link usually the day before your appointment.*

I understand my session will be online through zoom. I also understand that I will need tissues to wipe my face, a trash bag in case I need to spit in, and a quiet place with zero distractions.I have received prior approval from the ministry for a Face to Face session in the Prayer Room.
The deliverance team is trained to find and recognize every legal right in order to break it before we cast out demons. Sometimes in the first session, the team will send the person home with 'homework' and schedule a second session to cast out the demons. Common reasons for homework; The person needs to do forgiveness work, inner healing, or throw away accursed items from their home.*

I commit to my complete journey towards freedom and I recognize the importance of the full process. I commit to doing the necessary work required and I understand that the deliverance team will not cast out demons until all legal rights have been broken, which could result in a 1-2 sessions. I confirm that my expectations will not be let down if we do not cast out demons in the first session.
This ministry will NOT perform a deliverance on a NON-Christian:*

I am a Christian and led by the Holy Spirit.I am NOT a Christian but would like to invite the Holy Spirit into my life and become a Christian during deliverance. I recognize the spiritual world is real and I want to give my life to Christ and no longer partner with the demonic realm.
Please type below, word-for-word the whole confession and covenant you have with Jesus Christ: ------ I, (include your first and last name) confess that Jesus Christ is Lord and came in the flesh, died on the cross and three days later rose from the grave. God-the Father, Jesus-the Son, and the Holy Spirit are the only One I serve and no other god or false religion. I vow that I am not currently involved in the occult as a means to curse the body of Christ. I renounce the occult and all forms of witchcraft and I render all witchcraft curses and rituals null in void and powerless, in Jesus name. This is my confession and may I be bound to my word.*
Do NOT ONLY type your name in this box. Type the WHOLE confession: If you are unable to make this confession, please state why.
REQUIREMENTS
1.) During deliverance you will need to forgive and release ALL people who have hurt you. Forgiveness is a choice not a feeling. 2.) You must be ready to repent and turn from ALL sin and renounce it in deliverance. If you plan to continue in sinful and bad behaviors (pornography, pre-marital sex, homosexuality, masturbation, adultery, vaping, nicotine, weed, theft, Occult practices, etc.) then deliverance is not for you at this time. 3.) Lastly, you must be willing to be completely transparent and not keep anything from the deliverance team. Please carefully select the following choices that apply to you:*

I am willing to comply with all three requirements listed above.I am NOT ready or willing to forgive.I am NOT ready or willing to renounce all sin and bad behaviors.I am NOT ready or willing to be completely forthcoming and share everything pertaining to my history and life.
* If you checked any of the last three selections in the question above. Do not proceed in filling out the rest of this form. Deliverance is not for you at this time. Questions? Go to the "Contact Us" page on this website and submit your questions.
ANCESTRAL HISTORY
Psalm 58:3- "Even from birth the wicked go astray; from the womb they are wayward."

Demonic spirits can enter from the womb. Generational 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 (and your children) through your bloodline. Likely, you only know about your parents and each of their two parents. Your ancestral background is important in order to break generational curses passed down from generation to generation. To understand more about curses, read Deuteronomy chapters 27 and 28. We also highly recommend the book, "Blessing Or Curse: You Can Choose" by Derek Prince.
Are you aware of your ANCESTORS involvement in any of the following areas (not YOUR involvement):

I'm unaware of my ancestors because I was adoptedInvolvement with the OccultWitchcraftSatanic worshipSatanic ceremoniesHuman sacraficesAnimal sacraficesBlood covenants/ritualsThe BrotherhoodSanteriaRebellion Against GodPovertyIdolatrySexual PerversionIncest (sexual act/touch by family member)Sexual AbuseAlcoholismAddictionDrug AbuseDepressionSuicideMental DisordersMental IllnessPremature DeathsCancerUnexplainable Medical ProblemsBirths out of wedlockMiscarriagesBarrenessAbortionsMurderFought In WarsCriminal ActivityAngerDivorceAdulteryRosicrucianismFreemasonryMaster Mason (highest rank in Masonry)Thirty-Third Degree Mason (honorary members of the supreme council)Shriners International (spin off of Masonry)Knights of ColumbusRainbow GirlsJob's Daughters InternationalEastern StarConstellation of Junior StarsOrganization of TrianglesIlluminatiSecret SocietiesKKKNaziBlack PantherNew AgeWiccanJehovah WitnessMormonismScientologyOther Religions
Please explain any selections made above regarding your ancestry.
PERSONAL HISTORY
Select any involvement YOU ever had with the following. Even if only participated once and however innocent it seemed at the time. ONLY check if you know for sure you did it.

Ouija BoardDungeon and Dragons (game)Light as a feather, stiff as a board (game)Choking gameGames that predict your future"Blood Sisters" (prick finger with best friend)"Blood Brothers" (exchange blood for friendship)Bloody MaryMagic 8 BallLevitationAlters set up for idol worshipSatanic churchSatanic worshipContracts with SatanThe Brotherhood (in Satanism)The Sisters of Light (in Satanism)Demonic tonguesBlood covenantsHuman sacrificesAnimal sacrificesPentagramRitualsPotion drinkingTwin Flames"Love" rituals (cause someone to fall in love with you)El Ojo (The evil eye)Egg ritual (used to determine if "evil eye" is affecting you by "reading" the cracked egg and placing under bed)Susto ritual (Herbs, Tea leaves, prayer, to ward off a frightening experience)Curanderismo (folk medicine used with herbs, prayers, and rituals)Dead chicken with head cut off (witchcraft ritual)Entity Removal (New Age approach to 'removing' evil spirits from a person)CeremoniesAyahuasca CeremoniesSeancesTea leavesBurning SageHagstonesTalismansFetishesAmuletsWater witching (locating things underground by forms of divination)DivinationEnchanter (whisper a spell, prognosticate, soothsayer, practice magic)Charmer (to fascinate, to spell, join by spells, hypnosis)Consulter with Familiar SpiritsWitchWarlockWizard (conjurer, a ghost prognosticator, one who "knows" many things, magic)Sorceress (Pharmakia- medical poisoner, magic, a druggist, a magician, uses drugs and chemicals to a stupor)PsychicsFortune TellersPalm ReadingTarot cardsAngel cardsAngel boardsNegative Archie McPhee notebooks (encourages you to keep record and remember all your offenses)Death Notebook (leave note w/ friend in case you die with secret password so Medium can conjure you up)Contacting the dead (necromancy)Taphophile (obsession or interest in cemeteries, graveyards, funerals, gravestones)Graveyard ritualsMediumsSpiritist (claims to speak with the dead, like a Medium)Spirit GuidesWitchdoctorsWitchcraftVoodooSorceryMagicBlack magicWhite magicBooks about magicCrystal BallsCrystalsHealing crystalsCharmsIncantationsSpell booksCasting spellsInterpreting OmensAstral projectingTelekinesisESPHypnosisHand writing analysisAutomatic writingDark artsAstrologyNumerologyHoroscopesZodiac signsHeavy metalMetallica SandmanMarilyn MansonSlayer (band)Vemon (band)King Diamond (band)Incubus (band)Body PiercingsTongue ringBelly ringEar gaugesHelix barHalloweenHaunted housesHorror MoviesObsession with horror movies and goreHarry Potter books/moviesTwilight SeriesFifty Shades of GrayThe Secret (book or movie)Fascination with folkloreFascination with fantasyLaw of Attraction (manifesting positive and negative realities through thoughts)Law of Assumption (manifesting desires by believing you already have it)Vision/Dream boardsAffirmations (positive thinking, self empowerment)Pokemon cards/gameBakugan cards/gameYugioh cards/gameWatching Japanese Anime (animation)EnneagramVocal Transformation (ancient practice of using your voice "to balance your chakras for spiritual alignment")Transcendental meditationNew Age meditation practicesAncient meditation practicesMeditation retreatsGuided MeditationYogaCertified Yoga instructorKundalini YogaChakrasMantrasThird EyeChiropractorsCuppingEnergy healingReikiReiki MasterUsing a PendulumUsing a magnet over parts of your bodyEmotion Code/Body CodeAcupunctureKinesiologyReflexology (aka Zone Therapy)Eastern medicinesEssential oilsEastern practicesBooks on Eastern practicesQigongMartial ArtsBowing to Sensei (the master in martial arts)Kung FuJiu JitsuJudoTai ChiKarateAikidoTaekwondoFreemasonryMaster Mason (highest rank in Masonry)Thirty-Third Degree Mason (honorary members of supreme council)Shriners InternationalKnights of ColumbusEastern StarRainbow GirlOrganization of TrianglesConstellation of Junior StarsJob's Daughters InternationalOddfellowsIlluminatiFraternitySororityThe Landmark ForumCatholicismCatholic- First CommunionCatholic- Christening (Baby baptism)Catholic Sacraments (Baptism, Eucharist, Confirmation, Reconciliation, Anoint, Marriage, Ordination)Catholic worship of SaintsPraying the RosaryPraying salvation for the dead (purgatory)Native American spiritualismSanteriaPalo MayombeIslamMormonismMormon Proxy BaptismJehovah WitnessScientologySpiritulismHinduismKrishna (Hindu diety)Kali ( Hindu diety)Shiva (Hindu diety)ShaivismRastafarianismBuddhismTaoismKabbalahUniversalismWiccaNew AgeShamanismDrumming CircleSun DancingSpirit AnimalWorship of the UniverseWorship of stars, sun, moonSeeking enlightenment from GurusHigher level of consciousness (Nirvana, Enlightenment, Awakening, Truth)Using consciousness and determination to move energy (Qi, Life Force, Kundalini)'Speaking to the water' to manifest positivity in your lifeThe power of positive thinkingReincarnationEvolutionKarmaAtheism (does not believe in a god)Agnosticism (does not believe it is possible to know for sure if there is a god)SuperstitionsConspiracy theoriesGamblingAliens and UFO'SDrugsHallucinogensPsychedelics- drugs that specifically open you up to the spirit worldPlant medicinePeyoteDMTAyahuasca (liquid DMT)Bang- drinking cannabisSmoking CannabisTattoosTattoo- OccultTattoo- Memorializing the deadHenna Tattoos
*** If you are interested in understanding some of the caution behind Halloween, Yoga, Chiropractic, Martial Arts, Tattoos, Freemasonry, Essential Oils, Pokemon, Enneagram, Himalayan Salt Lamps, Dreamcatchers, Acupuncture, Cupping, Burning Sage, Horoscopes, and Astrology. Go to "Frequently Asked Questions" on this website and under the section, "Common Practices That Seem Innocent," you will find an explanation. ***
Out of the list above, please explain any practice you checked that you were heavily involved with. Also include anything we might have left out?
Are you willing to stop engaging and renounce any involvement you had in the list above in order to move forward in deliverance?

YesNo
If no, please explain.
If you participated in "blood sister" or "blood brother" ritual, please list the first name(s) of the people you joined with through blood.
We will need to break Soul Ties with these people
Did you love to watch horror movies?

YesNo
Do you currently believe in reincarnation? (You have past lives or when you die you come back to earth as someone else).

YesNo
Do you talk or communicate to the dead? (Speak to past loved ones or conjure their spirits up).

YesNo
If you talk to the dead in any form, please explain.
"Let no one be found among you... who consults or speaks to the dead. Anyone who does this is detestable to the Lord." Deuteronomy18:10-12
List the names of any drugs you took throughout your life. Also list if you ever used nicotine, alcohol, or abused prescriptions (name the prescription).
List any current or past addictions. Please NOTE which addictions are current. (Example: Sex, tobacco, caffeine, alcohol, drugs, shopping, food, prescriptions, gaming, gambling, etc.).
ACCURSED ITEMS
Do you have any accursed items in your home or possession attributed to the occult, idolatry, ungodliness, other religions, Eastern practices, witchcraft or cults? Select those that apply.

New Age BooksDream/Vision boards of any kind (even if it includes bible scripture)New Age affirmations (positive thinking, self empowerment)Negative Archie McPhee NotebooksDeath NotebooksBooks about Eastern deitiesBuddha statues or imagesIdolsJade (attached to other religions)DreamcatchersEssential OilsEastern MedicinesEastern PracticesChiropractic ItemsYoga ItemsMartial Art ItemsNative American Artifacts (some)Native American ArrowheadsAfrican Artifacts (some)Tribal Artifacts (some)Questionable souvenirs and jewelry from other countriesItems connected to other religions or ritualsRenaissance Festival ItemsMardi Gras ItemsWiccan ItemsKabbalah ItemsKabbalah BraceletThe Evil Eye BraceletFraternity ItemsSorority ItemsFreemasonry ItemsEastern Star ItemsIlluminati ItemsRainbow Girl Items (Freemasonry)KKK ItemsNazi ItemsThe KoranCatholic Saint StatuesCatholic AltersThe RosaryCatholic First Communion GownDrugsDrug ParaphernaliaBongsPipesHookahVapeElectronic CigarettesNicotine/TobaccoChewing TobaccoCigarettesCigarsMarijuanaPornographySex toysBDSM ItemsStolen ItemsVulgar ItemsHorror MoviesHeavy Metal MusicSkullsHalloween (decorations, costumes, etc.)PokemonBakuganYugiohJapanese AnimeSatanic ItemsWitchcraft ItemsPentagramsHagstonesTalismansFetishesAmuletsMarksOuija BoardTarot CardsAngel CardsTea LeavesBurning SageIncenseHoroscopesAstrologyZodiac signsEnneagram BookCrystal BallsCrystalsCharmsGood Luck CharmsOmensSuperstitious ItemsFairiesTrollsGnomesMagicMagic 8 BallPotionsSpell BooksIncantationsVoodoo DollsGames that predict futurePendulumsHimalayan Salt LampsOccult BooksFifty Shades of GrayTwilight SeriesHarry Potter BooksHarry Potter MoviesThe Secret (book or movie)Items or gifts from unhealthy relationships/soul tiesItems in your house that seem wrong or you feel you should not have themQuestionable pictures/Apps/music/pornography/texts/contacts to soul ties and unhealthy relationships in your phone
Deuteronomy 7:25-26 The Lord says, "You must burn up the images of other false gods; do not covet the silver and gold that is on them or take it for yourselves, or you will be ensnared by it; for it is detestable to the LORD your God. And you must not bring any detestable thing into your house, or you, like it, will be set apart for destruction. You are to utterly detest and abhor it because it is set apart for destruction."

Acts 19:19- "Many of those who had practiced magic (and witchcraft) brought their books (and occult items) together and burned them in the sight of all. And they counted up the value of them, and it totaled fifty thousand pieces of silver (equates to $2 million today)."
List any questionable items not mentioned above.
Are you willing to get rid of these items BEFORE deliverance (they are open doors/portals)?

YesNo
If you are not willing to get rid of the item(s), please explain.
Do you have any of these items in a storage unit? Before deliverance, they will need to be thrown out.

YesNo
BELIEFS AND BEHAVIORS
Please select which applies to you regarding DISCRIMINATION and JUDGEMENT. You can select more than one.*

I have physically abused peopleI have bullied peopleI was heavily bullied as a childI have abused or taken advantage of the handicapI have discriminated against the Jewish people (anti-semitism)I struggle with being judgmentalI am very critical towards peopleI lack sympathy towards peopleI am racist towards other ethnicitiesI believe my ethnicity is superiorI affiliated with Black Lives MatterI chanted, "Say My Name" with the BLM movementI affiliated with groups like KKK, Nazi, Black Panther, etc.None of the above apply to me
Please feel free to explain any of the selections made above that would be helpful to our team..
Please select which applies to you regarding IDENTITY and ABUSE. You can select more than one.*

I am adoptedMy parents are divorcedMy parents were never marriedI was born out of wedlockI was physically abused by my parentsI was physically abused by othersI was sexually abused by my parentsI was sexually abused by othersI was rapedI was molestedNone of the above apply to me
Please feel free to explain any of the selections made above that would be helpful to our team.
Were there any significant problems in the home, growing up? Explain.
Did you have imaginary friends as a child?

YesNo
If yes, what was their names?
If you experience any sexual abuse, touch, molestation, rape or sexual embarrassment, please explain.
Select which sexual acts you have EVER participated in, consensual or not. Do not leave anything out.*

I was conceived out of wedlock (my parents were not married when I was conceived)Incest (touch or sexual act with a family member)As a child, experimented with other children by touch or sexual acts (playing house)LustMasturbationMolestationRapePedophiliaPornographyPerversionPromiscuityProstitutionTopless DancingIndecent ExposureMardi Gras (topless)Fornication (premarital sex)AdulteryVoyeurism (watching others without their knowing, "peeping tom")Sexual FantasiesSexual FetishesOrgies (group sex)Swinging (husband and wife exchanging sex with other couples)DominartixBDSM (Bondage, Dominance, Submission, Masochism)Homosexuality (men having sex with men or the desire to)Lesbianism (women having sex with women or the desire to)Bisexuality (sexual relations with both genders or the desire to)Bestiality (sex with animals, arousal from watching animals have sex)Anal Sex (you penetrated someone)Anal Sex (someone penetrated you)Anal Sex in the marriage bedOral SexOral Sex in the marriage bedTongue ring for oral sexBody piercing on private partsSex change (medical procedure)Sexual encounters in your dreamsSexual encounters in your dreams with same sexExperiencing orgasms in your dreams ('wet dreams")Sexually Transmitted DiseasesAIDSHerpes
Please feel free to explain any selection above that would be helpful to our team.
Please list any sexual sin you are currently engaged in.
List the first name of premarital sex partners in order to break ungodly soul ties. If you can't remember names, please state that.
Please select which applies to you regarding SEXUAL IMMORALITY. You can select more than one.*

I have molested someoneI have raped someoneI have paid prostitutes for sexual actsI have sold myself for sexual actsI have watched pornographyI'am currently watching pornographyI'am currently masturbatingI have engaged in pre-marital sexI currently struggle with lustI have engaged in incest with my consentI have engaged in incest unwillinglyI have engaged in adultery while married to my current spouseMy current spouse does not know I committed adultery within our marriageI have engaged in adultery while married to my ex-spouseI was in a relationship with a person who was marriedI have committed sexual acts with animalsI have sexual thoughts about animalsI have watched videos of animals having sexNone of the above apply to me
Please feel free to explain any selection above that would be helpful to our team.
List the first name of the person(s) you committed adultery with in order to break soul ties.
It is important to understand that in order for your deliverance to be successful, the enemy can no longer have legal permission through concealing your infidelity. It is our experience that if a spouse has unconfessed adultery in the marriage, the evil spirit will manifest during the session but will NOT come out. Infidelity is a serious matter in God's eyes and it needs to be confessed to your spouse since the foundation of the marriage is unstable. At the root, there is secret sin against the marriage coupled with lies and deceit. Proverbs 28:13 says, "Whoever conceals their sins does not prosper, but the one who confesses and renounces finds mercy." Are you willing to confess the infidelity to your spouse?*

YesNoN/A
WIVES: Please select any that applies when intimate with your husband

FrigidityDreads intimacy with husbandDryness-unable to produce any natural lubricationBody freezes at the touch of your husbandBody painVaginal painNo sex driveUnable to climaxDid NOT experience these hinderances outside the marriage bed while fornicating, infidelity, masturbating, etc.
Please select which applies to you regarding CONCEPTION and SEXUAL IDENTITY. You can select more than one.*

I had an abortionI had multiple abortionsMEN: I conceived a child that was abortedMEN: I convinced my partner to abort our baby, when she did not want toI have taken "The Morning After Pill"I have experienced miscarriagesI am unable to get pregnantI affiliated with the LGBT communityI have experienced homosexual, bi-sexual, or lesbian relationshipsI have experienced homosexual, bi-sexual, or lesbian thoughtsI have experienced homosexual, bi-sexual, or lesbian dreamsI have experienced confusion regarding my genderI have identified as transgenderI have participated in altering my gender through medication or surgeryI have changed my birth name to fit my new identityI have dressed as a drag queenAs a woman, I prefer(ed) to dress like a manAs a man, I prefer(ed) to dress like a womanNone of the above apply to me
Please feel free to explain any selection above that would be helpful to our team.
Please select which applies to you regarding REBELLION and SINFUL NATURE. You can select more than one.*

I participated in a sorority or fraternityI participated in a branch of FreemasonryI was rebellious as a teenI am rebellious as an adultI am obsessed with getting tattoosI use foul language in my everyday talkI can't control myself from gossipI often lie or tell half-truths, I can't help myselfI have experienced legal troubleI have been to jailI struggle submitting to authorityI struggle submitting to my husbandI struggle with pride and arroganceI am stubbornI am defiantI do not like being told I am wrongI battle the need to be in controlI am terrified of feeling out of controlI often manipulate to get my wayI scheme and concoct ways to manipulate peopleI use intimidationI can be dominatingNone of the above apply to me
Please feel free to explain any selection above that would be helpful to our team.
If you experienced serious legal trouble, please explain.
Please list tattoos/meaning on body.
Leviticus 19:28- "Do not cut your bodies for the dead or put tattoo marks on yourselves. I am the LORD."
Please select which applies to you regarding FORGIVENESS and HEART POSTURE. You can select more than one.*

I am easily offended by othersI find myself offended towards people who have hurt my loved ones, and I am unable to forgive themI have struggled to forgive others in the pastI am currently walking in unforgivenessI am not ready to forgiveI do not know how to forgiveI struggle to forgive myselfI struggle with bitternessI struggle with resentmentI struggle with revengeI have done extensive work in forgiveness and I hold nothing against anyone who has wronged meI have zero offense, bitterness, revenge or hurt towards anyoneNone of the above apply to me
Please feel free to explain any selection above that would be helpful to our team.
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).
Why do you struggle to forgive yourself?
Please select which applies to you regarding DEPRESSION and ANXIETY. You can select more than one.*

I battle with depressionI have taken medication for depressionI am currently taking medication for depressionI feel there is a heaviness on me or around meI feel like there is a "black cloud" that follows meI battle sadnessI cry all the timeI feel hopelessI can not get out of bed, I am unmotivated to do anythingI experience feelings of self hateI have inflicted self-harm (includes cutting)I have had suicidal thoughts in the pastI currently have suicidal thoughtsI have attempted suicideI have panic attacksI battle anxietyI have taken medication for anxietyI am currently taking medication for anxietyI feel mentally tormentedNone of the above apply to me
Please feel free to explain any selection above that would be helpful to our team.
If you have attempted suicide or self-harm, please 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." "I should just die." "I am stupid and nobody cares."
Please select which applies to you regarding your SLEEPING PATTERNS. You can select more than one.*

I experience frequent nightmaresI often have pornographic dreams with sexual encountersI have experienced sleep paralysis (paralyzed while sleeping coupled with fear)I have reoccurring dreams with a person from a past relationship that I am no longer in contact withI battle insomnia (inability to sleep at night and mind racing at 3AM)I struggle with sleep walkingI struggle with fatigue with no medical explanationNone of the above apply to me
Please feel free to explain any selection above that would be helpful to our team.
Please list the first name of the person you have reoccurring dreams about, especially if they are sexual.
This is a possible soul tie.
Please select which applies to you regarding CONFUSION and EATING HABITS. You can select more than one.*

I suffer from confusionI am extremely disorganizedI am always late, even though I desperately try to be on timeI struggle with an eating disorderI battle anorexiaI battle bulimiaI battle gluttonyI struggle with obesityI am a veganI do not eat meat or food from animals because I believe it is wrong or badNone of the above apply to me
Please feel free to explain any selection above that would be helpful to our team.
Please select which applies to you regarding FEAR and PARANOIA. You can select more than one.

I am tormented by fearI experience fearful thoughts frequentlyI battle phobias that are unrealisticI battle OCDI have OCD ritualsI am terrified of germsI experience paranoiaI feel like I am being monitored by other people or authoritiesI hear voices that other people can not hearNone of the above apply to me
Please feel free to explain any selection above that would be helpful to our team.
Please list the name of phobias you experience (fear of germs, heights, cats, spiders, snakes, etc.).
Please select which applies to you regarding DOUBT, REJECTION, and ANGER. You can select more than one.

I am constantly battling doubt and unbeliefI am often skepticalI struggle to believe the supernaturalI struggle with rejection because I was rejected by my parentsI often feel rejectedI battle with insecurityI always feel worthlessI always feel unworthyI deserve what I am going throughGod will never forgive meI struggle with guilt and shameI always feel condemned, instead of God's grace and mercyI have been angry towards GodI am currently angry towards GodI battle intense angerI often lash out at peopleI can be provoked to rageI feel irritated and frustrated oftenI have murderous thoughtsNone of the above apply to me
Please feel free to explain any selection above that would be helpful to our team.
Select if any apply regarding money. You can choose more than one.

Worry and anxiety over moneyTormenting fear of losing money and not having enoughMoney mismanagementConsistent financial lack"I can't afford it" mentalityImpulse buyingStinginessStinginess towards tithingGreedPovertyDiscontentment- never enough no matter how much you saveBondage of debtExaggerated emphasis on moneyStrong belief money is your security over God's provisionNone of these apply to me
TRAUMA AND INNER HEALING
From birth to early childhood: Are you aware of any trauma you might have experienced during your mother’s pregnancy? Car accident, attempted abortion, divorce, spoken words such as, "I do not want this child," or the cord being wrapped around your neck, almost dying at birth, etc.? Please identify and explain.
Do you currently struggle with trauma from a past traumatic experience or time in your life?

YesNo
Please list any traumatic experiences you encountered.
Please list accidents or injuries that were traumatic.
Have you received inner healing or counsel dealing with this past trauma?

YesNoYes, but I'm still in the process and need more inner healing
Briefly explain ANY counseling, inner healing, Sozo, or ministry you have ever received in the past and what was accomplished? This question is not only for traumatic experiences.
MEDICAL HISTORY
Please list any medical diagnosis you received from a doctor? (Example: Diabetes, Asthma, Hypertension, Autoimmune, Cancer, Heart Disease, etc.)
Please list any mental disorders you have been diagnosed with. (Example: ADHD, OCD, Bi-Polar, Dyslexia, Schizophrenia, Aspergers, Autism, etc.).
Please list any generational sickness or disease in your family history. (Example: Tuberculosis, Diabetes, Ulcers, Cancer, Heart disease, Asthma, Autoimmune, Autism, ADHD, ADD, Dyslexia, Bi-Polar, or ANY other diagnosis).
Do you have any transplants? Please explain.
BEFORE YOU GO
Is there any behaviors/sins/experiences you believe would be helpful that was not mentioned on this form? Ask the Holy Spirit to bring it to your mind.
Additional comments for the team, questions or concerns.
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 2 sessions in order to be completely free. Evil spirits travel in packs and we have never seen or led a deliverance where only one spirit was present. This is why some 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 helping us deliver you from demonic oppression.

Deliverance will take several hours, we suggest you wear comfortable clothes. Ladies, please wear clothing that completely covers your chest, stomach, and upper legs. Please no skirts or dresses. We are unaware of how you will manifest during deliverance and if you wear a low-cut shirt, you can be exposed during deliverance. Our top priority is that you are treated with the utmost respect and dignity.

It is important to understand that when you experience genuine deliverance and evil spirits leave your body; You will feel lighter, your mind will stop racing, your ability to connect with God won't be hindered, your specific manifestations will stop, you will not feel pain, you could experience healing, 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 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.
It is important that you read the entire 'Frequently Asked Questions' (FAQ) page on this website BEFORE your session. It is extremely important to be fully aware of what is required for a successful deliverance. By reading the FAQ page, it will also prepare you for what to expect. Knowledge is key and the truth will set you free!*

I have already read the entire FAQ page on this website. I am prepared for what to expect in deliveranceI have NOT read the FAQ page on this website, but I will commit to reading it before my deliverance
Are you willing to participate in a 24-hour liquid fast the day before your deliverance session(s)?*

YesNoI am pregnant or experiencing health limitations. I will fast sweets, social media, TV, or something I enjoy for at least 24-48 hours before deliverance.
SESSION FEES
- Zoom Deliverance, per session: $200.00
- Face to Face deliverance, per session (pre-approval only): $300.00
It is important to understand that you are not paying to receive freedom. Deliverance is free. This fee pays the team for the considerable amount of time, services, and resources dedicated to your journey for freedom. This is a full-time ministry.

Please do not submit this form, if you do not have intentions of submitting payment. We will not schedule your appointment until payment has been received. We advise after you submit this form, find the "PURCHASE" tab on the website and submit payment.

The fee is non-refundable. You have the flexibility to reschedule as long as you cancel your original appointment 24 hours in advance. If you consecutively reschedule the same appointment, the deliverance team has the choice to not continue rescheduling the session.
Agreement:*

I would like to purchase a zoom deliverance, totaling $200.00. I will pay the full amount upfront (found on the website under PURCHASE) after I submit this form.I have been given prior approval from the ministry for Face to Face deliverance in the prayer room. I would like to purchase the face to face session, totaling $300.00. I will pay the full amount upfront (found on the website under PURCHASE) after I submit this form.For The Brokenhearted donated a complimentary session to me.
CANCELLATIONS
The deliverance fees are non-refundable but you have the flexibility to reschedule your session at a different time as long as you notify the ministry of your cancellation within 24 hours. In the case that you have to cancel your deliverance session, we ask that you kindly notify us at least 48 hours before your appointment. Our desire is to give your time slot to another person since our current scheduling is weeks out. The deliverance team begins to pray and fast for each deliverance 24 hours prior to the appointment and we need enough time to prepare. If you request multiple reschedules in a row, the deliverance team has the option to not reschedule with you.
Agreement:*

I understand that if I cancel my deliverance session without a 24 hours notice, I will forfeit the ability to reschedule and there will be no refund. I also understand that the deliverance fees are non-refundable.
LIABILITY RELEASE FORM

Must be signed before deliverance
For The Brokenhearted Ministry 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 Ministry 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.

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.

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 Ministry and its agents, staff, employees, and volunteers of any damages, real or perceptual, arising from personal ministry in connection with the information submitted herein.

1.) I release, waive, discharge and covenant not to sue For The Brokenhearted Ministry, their officers, servants, agents, volunteers, staff or employees from any and all liability, claims, demands, actions and causes of action whatsoever arising out of or related to any loss, damage, or injury, including death, that may be sustained by me, or to any property belonging to me, whether caused by the negligence of the Ministry or otherwise, while participating in such activity, or while online or in, on or upon the premises where the activity is being conducted.

2.) I am fully aware of risks and hazards connected with the activity, and I elect to voluntarily participate in the activity, and to engage in such activity knowing that the activity may be hazardous to me and my property. I voluntarily assume full responsibility for any risks of loss, property damage or personal injury, including death, that may be sustained by me, or any loss or damage to property owned by me, as a result of being engaged in such an activity, whether caused by the negligence of the Ministry or otherwise.

3.) I further agree to indemnify and hold harmless the Ministry from any loss, liability, damage or costs, including court cost and attorney fees, that they may incur due to my participation in the activity, whether caused by negligence of the Ministry or otherwise.

4.) It is my express intent that this Release and Hold Harmless Agreement shall bind the members of my family and spouse, if I am alive, and my heirs assigns and personal representative, if I am deceased, and shall be deemed as a release, waiver, discharge, and covenant not to sue the above named Ministry. I further agree that this Waiver of Liability and Hold Harmless Agreement shall be construed in accordance with the laws of the State of Texas.

In signing this release, I acknowledge and represent that I have read the above Waiver and Liability and Hold Harmless Agreement, understand it and sign it voluntarily as my own free act and deed; no oral presentations, statements, or inducements, apart from the foregoing written agreement, have been made; I am at least eighteen (18) years of age and fully competent; and I execute this Release for full, adequate and complete consideration fully intending to be bound by same.

First Name*   Last Name*   Name of person requesting deliverance (18 or older)

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PRE-DELIVERANCE FORM

DELIVERANCE HOURS

PERSONAL INFORMATION

BEFORE YOU START

REQUIREMENTS

ANCESTRAL HISTORY

PERSONAL HISTORY

ACCURSED ITEMS

BELIEFS AND BEHAVIORS

TRAUMA AND INNER HEALING

MEDICAL HISTORY

BEFORE YOU GO

PREPARATION FOR DELIVERANCE

SESSION FEES

CANCELLATIONS

LIABILITY RELEASE FORM