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 several sessions. We recommend that if you have underwent mass (group) deliverance at an alter, 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 deliverance, you will also receive 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 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 can 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.
We do not charge a set fee for the actual deliverance session. However, love offerings are requested BEFORE each deliverance session. Your offering is what helps to support the ministry and honors the amount of time invested into your personal one-on-one deliverance; which results in counsel, discipleship, legality work, 4-6 hour deliverance session(s), fasting, prayers, and team meetings.

If you would like to sow into this ministry and become a monthly partner, there is a tab on the website labeled "GIVE" and you can set up a one-time donation or recurring monthly.
Information

HINT: We recommend using a desktop computer to fill out this form.
Name *

First Name Last Name
Today's Date *

Month Day Year
Date
Gender *
Age *
CELL Number (only) *

Area Code Phone Number
Email *
example@example.com
What city and state do you live in? *
Spouse 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? Who referred you? *
Occupation?
What type of work are you involved in
Deliverance Hours:

Monday thru Friday

11:00am- 5:00pm

* With the current demand for deliverance, we are booking 1 month in advance. Your patience is appreciated.
For people outside the Houston, Texas area and do not want to drive to be face-to-face; we provide Zoom (video conferencing) deliverance sessions for you as well. Zoom deliverances are just as effective as face-to-face. (FOR SAFETY PURPOSES: with Covid on the rise be prepared that you may be asked to participate in a zoom deliverance even if you request a face-to-face session).

Yes, I live outside the area and will require Zoom deliverance Even though I live in the area, I prefer to schedule a Zoom deliverance I would like to schedule a face-to-face deliverance in The Prayer Room
Do you have any previous marriages (other than your current)?

Yes No
How many previous marriages?
Provide the first name (only) of previous spouse(s).
Are you pregnant? (Yes, we will perform deliverance on women who are pregnant)

Yes No
How many months pregnant?
Are you a Christian (Born-Again)? *

Yes No
Age of Christian conversion?
This ministry will NOT perform a deliverance on a Non-Christian. According to Jesus in Matthew 12:43-45, if an evil spirit is cast out of an unbeliever and they do not receive the Holy Spirit, the person is considered "unoccupied." The evil spirit will return with seven more evil than itself, resulting in the person being worse than before deliverance. After deliverance, the leading of the Holy Spirit is vital from preventing you in opening demonic doors again. The only way to be led by the Holy Spirit is to invite him into your life and that is made possible when you become a Christian. Select which applies to you below: *

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 God and came in the flesh, died on the cross and three days later arose from the grave and now sits at the right hand of God the Father. This Jesus is my Lord, Savior and Master. The one I serve. *
Type the whole confession: If you are unable to make this confession, please state that you are unable to make the confession and why.
In order to move forward in deliverance, there are a few guidelines that MUST BE MET in order to have a successful deliverance. Otherwise, the legal-rights that give the enemy permission will not be broken and the evil spirit(s) do not have to leave. 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. Hiding any information will grant access to the unclean spirits. It will be a waste of time to move forward if any of these conditions are not met. 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.
Have you been water baptized?

Yes No
Age of baptism?
Do you speak in tongues through the Holy Spirit?

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

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

Yes No N/A
Which demonic spirits do you need deliverance from? *
List the top three sins you struggle with? *
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:

I'm unaware of my ancestors because I was adopted Involvement with the Occult Witchcraft Satanic worship Satanic ceremonies Human sacrafices Animal sacrafices Blood covenants/rituals The Brotherhood Santeria Rebellion Against God Poverty Idolatry Sexual Perversion Incest (sexual act/touch by family member) Sexual Abuse Alcoholism Addiction Drug Abuse Depression Suicide Mental Disorders Mental Illness Premature Deaths Cancer Unexplainable Medical Problems Births out of wedlock Miscarriages Barreness Abortions Murder Fought In Wars Criminal Activity Anger Divorce Adultery Freemasonry Master Mason (highest rank in Masonry) Thirty-Third Degree Mason (honorary members of the supreme council) Shriners International (spin off of Masonry) Knights of Columbus Rainbow Girls Job's Daughters International Eastern Star Constellation of Junior Stars Organization of Triangles Illuminati Secret Societies KKK Nazi Black Panther New Age Wiccan Jehovah Witness Mormonism Scientology Other Religions
Please explain any selections made above regarding your ancestry.
Please list the ethnicity from both of your parents in order to help us know what types of culture and practiced religions your ancestors were involved in? (Example: American, Mexican, Asian, Native-American, African-American, Italian, German, Russian, Turks, Irish, English, French, Polish, Celtic, Viking, Egyptian, Scottish)
Select any involvement YOU ever had with the following. Even if only participated once and however innocent it seemed at the time.

Ouija Board Dungeon and Dragons (game) Light as a feather, stiff as a board (game) Choking game Games that predict your future "Blood Sisters" (prick finger with best friend) "Blood Brothers" (exchange blood for friendship) Bloody Mary Magic 8 Ball Levitation Alters set up for idol worship Satanic church Satanic worship Contracts with Satan The Brotherhood (in Satanism) The Sisters of Light (in Satanism) Demonic tongues Blood covenants Human sacrifices Animal sacrifices Pentagram Rituals Potion drinking Twin 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) Ceremonies Ayahuasca Ceremonies Seances Tea leaves Burning Sage Hagstones Talismans Fetishes Amulets Divination Water witching (locating things underground by forms of divination) Psychics Fortune Tellers Palm Reading Tarot cards Angel cards Contacting the dead (necromancy) Mediums Spiritist (claims to speak with the dead, like a Medium) Spirit Guides Witchdoctors Witchcraft Voodoo Sorcery Black magic Books about magic Crystal Balls Crystals Charms Incantations Spell books Casting spells Interpreting Omens Astral projecting Telekinesis ESP Hypnosis Hand writing analysis Automatic writing Dark arts Astrology Horoscopes Zodiac signs Heavy metal Metallica Sandman Marilyn Manson Slayer (band) Vemon (band) King Diamond (band) Incubus (band) Body Piercings Tongue ring Belly ring Ear gauges Helix bar Halloween Haunted houses Horror Movies Obsession with horror movies and gore Harry Potter books/movies Twilight Series Fifty Shades of Gray The Secret (book or movie) Fascination with folklore Fascination with fantasy Law of Attraction belief Pokemon cards Pokemon games Watching Japanese Anime (animation) Enneagram Yoga Chakras Mantras Third Eye Ancient meditation practices Chiropractors Cupping Energy healing Reiki Reiki Master Using a Pendulum Using a magnet over parts of your body Emotion Code/Body Code Acupuncture Kinesiology Reflexology (aka Zone Therapy) Eastern medicines Essential oils Eastern practices Books on Eastern practices Martial Arts Bowing to Sensei (the master in martial arts) Jiu Jitsu Freemasonry Master Mason (highest rank in Masonry) Thirty-Third Degree Mason (honorary members of supreme council) Shriners International Knights of Columbus Eastern Star Rainbow Girl Organization of Triangles Constellation of Junior Stars Job's Daughters International Illuminati Sorority Fraternity The Landmark Forum Catholic worship of Saints Catholicism Praying salvation for the dead (purgatory) Santeria Palo Mayombe Islam Mormonism Jehovah Witness Scientology Spiritulism Hinduism Buddhism Taoism Shamanism Kabbalah Wicca New Age Worship of the Universe Worship of stars, sun, moon Superstitions Drugs Hallucinogens Psychedelics- drugs that specifically open you up to the spirit world Tattoos Henna 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?

Yes No
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
Please list any specific superstitions you have ever followed, even if you are not doing them today (see examples below).
EX: Knocking on wood, The Evil Eye, physically touching whatever you "covet" or admire in order to ward off envy spirits, break a mirror which results in bad luck, throwing salt over your shoulder, lucky pennies or horseshoes, Friday the 13th, black cats, crossing fingers, step on a crack.
List any horror movies or horror TV programs that you remember watching?
Nightmare on Elm, Halloween, Friday 13, Chucky, Misery, Blaire Witch, The Conjuring, Amity Horror, IT, Exorcist, Poltergeist, Scream, Tx Chainsaw, The Ring, The Shining, Sinister, Insidious, Steven King, The Nun, Saw, Paranormal Activity, The Witch, etc.
Did you love to watch horror movies?

Yes No
Do you believe in reincarnation? (You have past lives, or when you die you come back to earth as someone else).

Yes No
Do you talk or communicate to the dead? (Speak to past loved ones or conjure their spirits up).

Yes No
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
Did you abuse alcohol, smoke or take drugs?

Yes No
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 (tobacco, caffeine, alcohol, drugs, shopping, food, prescriptions, gaming, gambling, etc.)?
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 Books Books about Eastern deities Buddha statues or images Idols Jade Dreamcatchers Essential Oils Eastern Medicines Eastern Practices Chiropractic Items Yoga Items Martial Art Items Native American Artifacts (some) Native American Arrowheads African Artifacts (some) Tribal Artifacts (some) Questionable souvenirs and jewelry from other countries Items connected to other religions or rituals Renaissance Festival Items Mardi Gras Items Wiccan Items Kabbalah Items Kabbalah Bracelet The Evil Eye Bracelet Fraternity Items Sorority Items Freemasonry Items Eastern Star Items Illuminati Items Rainbow Girl Items KKK Items Nazi Items The Koran Catholic Saint Statues Catholic Alters The Rosary Drugs Drug Paraphernalia Bongs Pipes Hookah Vape Electronic Cigarettes Nicotine/Tobacco Chewing Tobacco Cigarettes Cigars Marijuana Pornography Sex toys ( Ex: dildo, for masturbation purposes) BDSM Items Stolen Items Vulgar Items Horror Movies Heavy Metal Music Skulls Halloween (decorations, costumes, etc.) Pokemon Cards Pokemon Games Japanese Anime Satanic Items Witchcraft Items Pentagrams Hagstones Talismans Fetishes Amulets Marks Ouija Board Tarot Cards Angel Cards Tea Leaves Burning Sage Incense Horoscopes Astrology Zodiac signs Enneagram Book Crystal Balls Crystals Charms Good Luck Charms Omens Superstitious Items Fairies Trolls Gnomes Magic Magic 8 Ball Potions Spell Books Incantations Voodoo Dolls Games that predict future Pendulums Himalayan Salt Lamps Occult Books Fifty Shades of Gray Twilight Series Harry Potter Books Harry Potter Movies The Secret (book or movie) Items or gifts from unhealthy relationships/soul ties Items in your house that seem wrong or you feel you should not have them
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."
List any questionable items not mentioned above.
Are you willing to get rid of these items BEFORE deliverance (they are open doors/portals)?

Yes No
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.

Yes No
Have you ever mistreated the handicapped?

Yes No
Have you ever bullied or abused people?

Yes No
If yes, please explain.
Have you ever participated in Anti-Semitism (hostility or prejudice against Jewish people)?

Yes No
Do you struggle with judgement, criticism, or hate towards other races?

Yes No
Do you support or are you affiliated with Black Lives Matter?

Yes No
Did you chant "Say my name?"

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 you adopted?

Yes No
If yes, do you know why you were given up for adoption? Do you have any communication with your biological parents?
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.
Did you have imaginary friends as a child?

Yes No
If yes, what was their names?
Did you experience 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."
Any physical abuse from parents or others? Please explain.
Did you experience any sexual abuse, touch, molestation, or sexual embarrassment through childhood? Explain.
Select which sexual acts apply to you throughout your life.

Incest (touch or sexual act with a family member) As a child, experimented with other children by touch or sexual acts (playing house) Masturbation Molestation Rape Pedophilia Pornography Perversion Promiscuity Prostitution Topless Dancing Indecent Exposure Mardi Gras (topless) Fornication (premarital sex) Adultery Lust Sexual Fantasies Orgies (group sex) Swinging (husband and wife exchanging sex with other couples) Dominartix BDSM (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) Anal Sex (you penetrated someone) Anal Sex (someone penetrated you) Oral Sex Tongue ring for oral sex Body piercing on private parts Sex change (medical procedure) Sexual encounters in your dreams Sexual encounters in your dreams with the opposite sex Sexual encounters in your dreams with same sex Experiencing orgasms in your dreams
Have you been exposed to pornography?

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

Yes No
Are you currently masturbating?

Yes No
Please list any sexual sin you are currently engaged in.
Have you engaged in premarital sex?

Yes No
List the first name of premarital sex partners (in order to break ungodly soul ties). If you can't remember names, please state that.
Do you have lustful thoughts?

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

Yes No I was in a relationship with a person who was married
List the first name (only) of the person(s) you committed adultery with?
Does your spouse know you committed adultery against them?

Yes No N/A
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? *

Yes No N/A
Have you had an abortion?

Yes No I fathered a child that was aborted
How many abortions?
Have you taken the "Morning After Pill?"

Yes No
Have you experienced a miscarriage?

Yes No
How many miscarriages?
Do you experience either homosexual, bisexual, or lesbian thoughts or tendencies?

Yes No
Do you experience confusion regarding your gender?

Yes No
Please explain above, if necessary.
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."
Participated in college fraternities or sororities?

Yes No
Were you rebellious?

Yes No
Wives, do you struggle submitting to your husband?

Yes No N/A
Did you affiliate with any feminist movement or way of thinking (women's freedom, burn your bra's, liberation, men are the problem, unbridled freedom, etc.)?

Yes No
Do you struggle submitting to authority?

Yes No
Have you experienced legal trouble?

Yes No
If yes, please explain.
Do you struggle with pride or arrogance?

Yes No
Are you defiant?

Yes No
Are you stubborn?

Yes No
Is it difficult for you to receive correction or constructive critique?

Yes No
Do you see yourself as always right?

Yes No
Are you tormented with guilt and shame?

Yes No
Are you tormented with hopelessness?

Yes No
Are you tormented with loneliness?

Yes No
Do you struggle with isolation?

Yes No
Have you struggled to forgive others?

Yes No
Are you currently walking in unforgiveness?

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
Have you ever had suicidal thoughts?

Yes No
Have you attempted suicide?

Yes No
If yes, please explain.
Do you recognize that the demonic will speak through your thoughts?

Yes No
Do you hear voices (demonic thoughts)?

Yes No
If yes, please give example.
Do you see in the supernatural realm? Angels, demons, etc.

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

Yes No
Do you experience sleep paralysis (paralyzed while sleeping coupled with fear)?

Yes No
Do you experience sexual encounters in your dreams?

Yes No
Do you experience sexual encounters with the same sex in your dreams?

Yes No
Do you have recurring dreams with a person from your past that you no longer have an intimate relationship with?

Yes No
If yes, please list their first name only.
This is a possible soul tie.
Do you suffer from Insomnia (inability to sleep at night, mind racing at 3:00am).

Yes No
Do you suffer from sleep disorders?

Yes No
Do you sleep walk?

Yes No
If yes, please explain. (For example; do you sleep walk and eat? Do you do certain things while sleep walking)?
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 experience pain with no medical explanation?

Yes No
If yes, please explain.
Please list accidents or injuries that were traumatic?
Do you have any transplants? Please explain.
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, ADD, Dyslexia, Bi-Polar, or ANY other diagnosis? Please list.
Have you been diagnosed with mentally defined disorders? (Ex: ADHD, OCD, Bi-Polar, Dyslexia, Schizophrenia, Aspergers, Autism, etc)?

Yes No
If yes, please list and explain.
Do you suffer from anxiety or panic attacks?

Yes No
Do you experience frequent headaches?

Yes No
Do you struggle with an eating disorder?

Yes No
If yes, please explain.
Do you have a compulsion to restrict certain food groups from diet (Veganism, meats, dairy, etc)?

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

Yes No
Are you plagued with doubt and unbelief?

Yes No
Do you feel rejected?

Yes No
If yes, please explain.
Do you battle insecurity? (On a scale of 1-10 with 10 being the worst).
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
Select if any apply regarding money (you can choose more than one).

Worry and anxiety over money Tormenting fear of losing money and not having enough Money mismanagement Consistent financial lack "I can't afford it" mentality Impulse buying Stinginess Stinginess towards tithing Greed Poverty Discontentment- never enough no matter how much you save Bondage of debt Exaggerated emphasis on money Strong belief money is your security over God's provision None of these apply to me
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 apply 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. Sexual dreams with people other than your spouse. Sexual dreams with people of the same sex. Sexual dreams with people from past relationships. Frequent or uncontrollable yawning. Sleep disorders. Sleep walk 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. Mental Illness Multiple personalities. Compulsion to lie, exaggerate or steal. Alcohol or drug abuse (especially with demonic hallucinations). Addiction 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 DEEPLY struggled with and would like to renounce.

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 Skepticism Blame Frustration Resentment Unforgiveness Irritability Intolorance Rage Anger Lashing out Murderous thoughts Revenge Retaliation Confrontational Guilt Shame People-Pleasing Compromise Indecision Indifferent Intimidation Inadequecy Daydreaming Fantasy Disorder Procrastination Fatigue Tiredness Laziness Attention-Seeking Orphan Spirit 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 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 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.

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 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 demons are removed, God is still breaking things down. He is peeling layers of hurt, layers of lies, layers of strongholds, layers of father-wounds through the sanctification process. Day after day he is setting you apart to look more like Jesus, which can result in life feeling temporarily more difficult than before you began. Be patient!
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 deliverance I 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)? *

Yes No I 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.
Love Offerings

Love offerings are requested BEFORE each deliverance session you may require. Your offering is what helps to support the ministry and honors the amount of time invested into your personal one-on-one deliverance; which results in counsel, discipleship, legality work, 4-6 hour deliverance session(s), fasting, prayers, and team meetings. For your convenience, there is a page on this website where you can give. Cash is also accepted on the day of each session. If you would like to sow into this ministry and become a monthly partner, there is a tab on our website labeled "Give" and you can set up a one-time donation or recurring monthly.
Please select one: *

I am honored to give a love offering to the ministry BEFORE each deliverance session I may require. I am currently unable to contribute a love offering.
Scheduling Fee

Beginning September 2021, a $25.00 non-refundable fee is required in order to schedule a deliverance session. This fee is to confirm and hold your appointment and give you the flexibility if you need to reschedule or cancel. Paying this small fee will also help to qualify the importance of deliverance to the one seeking freedom. In order for an appointment to be scheduled, you can go to the tab on the website called, "give" and make a one-time payment of 25.00. Or Venmo: venmo.com/forthebrokenhearted *** After we receive payment, we will reach out to schedule your session.
I understand there is a $25.00 scheduling fee in order to book an appointment. I can pay the fee on the website titled, "Give." *

Yes No
Cancellations

In the case that you have to cancel your deliverance session, we ask that you notify us 48 hours before your appointment. Our desire is to give your time slot to another person since our current scheduling is about a month 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.
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 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

First Name   Last Name Name of parent or legal guardian (if under 18)
(Parent or legal guardian must sign on the signature line below)

Draw your signature by clicking the tiny pen icon on the signature line below.

Signature*

Date*
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Pre-Deliverance Form

Information

Common Symptoms of Demonic Attack

Sins and Behaviors

Preparation For Deliverance

Love Offerings

Scheduling Fee

Cancellations

Liability Release Form