PEACEMAKERS INNER HEALING, Inc pre-deliverance form
Please be detailed with this form so we can assess root issues as we are preparing to provide you services. Please be mindful to include the following: information regarding any unresolved life hurts and experiences, childhood issues, teenage issues, young adult and adult issues, marital and relationship issues, church hurts, rape, incest, molestation, childhood sexual play, character issues and flaws, sin issues, generational curses, soul ties, forgiveness issues, hindrances, and disobedience issues to shifting forth in God identity, and in your destiny, purpose and calling. Also, please explore and list any personal, family, and generational witchcraft, idolatry, or paganism practices, or oppressions. The more detailed you are the more effective your services will be.
Name
First Name
Last Name
Date of Birth
Please select a month
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Month
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Day
Please select a year
2025
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Year
Age
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
What is your Time Zone?
Phone Number
-
Area Code
Phone Number
Gender
Female
Male
Marital Status
Single
Married
Divorced
Widowed
Occupation
Employer
Referred by:
Emergency Contact: Please list name, phone number, and address
Name of Church Home and address
Have you given your life to Christ
Yes
No
If the above answer is yes, what was the approximate date?
Baptism of Holy Spirit with evidence of Speaking in Tongues?
Yes
No
If the above answer is yes, how often?
Have you received Peacemakers Inner Healing Services before?
Yes
No
Desired Services
Personality Development (Dissociative Identity Disorder) (6 sessions or more)
Coaching (3 month commitment)
Mentoring (6 month commitment)
Deliverance Session
Emergency Preparedness Consultation
Book Publishing Consultation
40 Minute Strategic Consultation
60 Minute Strategic Consultation
80 Minute Strategic Consultation
Concerns: What reasons do you want to receive services?
Please describe any significant events that occurred during the time of or since the concern started.
Are you having difficulty or stressors currently?
Are there any specific behaviors, actions, or habits that you would like to change?
Listed below are common triggers, please check one or more boxes of things that trigger or “push your buttons.” Ask the Lord to highlight any additional triggers and record them below*
Inadequacy/Insecurity
Fear/Terror
Anxiety
Rejection
Abandonment
Humiliation
Betrayal
Anger/Rage
Guilt
Shame
Hopelessness
Helplessness
Feeling Stuck
Cannot hear God for Insight
List any additional triggers, frustrations, or challenges you have
Please list any demonic strongholds you believe are oppressing you.
Please list any personal curses oppressing your life
Please list any generational curses oppressing your life.
Are you or anyone in your family line apart of the following organizations(Choose all that apply)?
Freemason
Eastern Star
Job's Daughters
Sorority
Fraternity
Any Secret Society
Medical History
List any complications during your birth(Ex: premature, c-section, birth trauma, etc.)
List any medical conditions or history(including mental illness, addictions or hospitalizations)
List any pains you have in your body that may be undiagnosed?
Do you have a learning disability?*If yes, please specify
Family History
Place a mark in the column for involvement on the lines of any other following to you or your family line.
Past
Current
Generational
Astrology
Astral Projection
Black Magic
Demon Worship
Divination
Fortune Telling
Horoscopes
Mediumship
Mental Telepathy
Mind Control
Occult Control
Palm Readings
Pendulum Readings
Psychic Reading
Reincarnation
Seances
Superstition
Sorcery
Tarot Cards
Trance
White Magic
Witchcraft
Voodoo
Occult Sex/ Ritual Abuse
Buddhism
Christian Science
Eastern Religions
Hinduism
Islam
Indian Occult Rituals
Jehovah's Witnesses
KKK
Masons
Mormonism
New Age Movement
Satanic Worship
Spirit Guides
Scientology
Shamanism
Shrines
Spiritualism
Unitarian Church
Others
If you selected "Others" in the above question please list other involvement and list if it is past, current, or generational.
What is the ethnic background of your descendants?
List any history of mental illness or addictions in immediate or extended family Ex: Depression, anxiety, bi-polar, suicide attempts, alcoholism, drugs, ADHD, schizophrenia, etc.
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Are you adopted?
Yes
No
Briefly give parents' marital history(Ex: married, divorces, step parents, live-ins, etc.)
Please explore and list any personal, family, or generational witchcraft, idolatry, or paganism practices or oppressions. Be open with the Lord and allow him to show you.
Trauma History
Please list the trauma you have experienced in your life?
Please list any trauma you experienced related to 2020 (Ex. Covid-19, death, hardship, racial injustice issues, etc.)
Please indicate the days and times generally work best for you regarding your service. Services are generally done between 6am to 4pm on Tuesday, Wednesday, Thursday, and Saturday
Please place a check mark for acknowledgement
Peacemakers Inner Healing, Inc reserves the right to cancel my Services at any times at their discretion, and will notify me if services have been terminated.
Signature
PEACEMAKERS INNER HEALING, Inc. AGREEMENT
(Acknowledgment of services)
I understand the following:
When my sessions are scheduled, I am responsible of meeting with or calling my counselor(or mentor, consultant, coach) at the scheduled time of my session. If I need to reschedule my session I must do so at least 24 hours in advance. My counselor (mentor, consultant, coach) will not be calling me for my session, and she/he will initiate the rescheduling of sessions.
I understand it is expected that I am to cooperate fully with my Minister and with the Holy Spirit in order to facilitate receiving God’s help. My Minister may ask me to pray, fast, or do some outside ‘homework’ in conjunction with my ministry. They also may ask me to be accountable to them for some specific areas of my life or for some specific behaviors.
If I "no show" for an appointment, I will not be able to reschedule except in cases of extreme emergency. It is imperative that I honor my time and commitment to my dreams and progress. If I " no show" it is my responsibility to initiate the scheduling of my next session. My counselor (or mentor, consultant, coach) will not be initiating the rescheduling of "no show" sessions.
My services are confidential. However, Peacemakers Inner healing, Inc , has duty to report to authorities and or the appropriate mental health facilities when I am a threat to myself or others.
Clients may be encouraged to partake of online or conference call teaching, prayer sessions. I understand that this is not for personal relationship or ministry relations. It is to further assist clients in their healing and wellness.
I agree that my ministers may give a verbal or written summary report of the ministry to the Director of PEACEMAKERS and or their designated representatives concerning their ministry to me with the purpose of providing me with more effective ministry.
I accept and acknowledge that PEACEMAKERS Leadership or any other persons involved in working with adults and children in a helping setting, are either encouraged or required by law to disclose to the appropriate person, agency, or civil authority, any harm or potential harm that a person may attempt or desire to do to himself/herself or to others.
Release of Liability Waiver
Please read and acknowledge understanding by you signature
Waiver: In consideration of being able to participate any services provided by Peacemakers Inner Healing, Inc, I for myself, my heirs, personal representatives or assigns, hereby release, waive, discharge, and covenant not to sue or hold liable G. Renee, Peacemakers Inner Healing, nor any assigned sponsors, speakers, partners, contractors, affiliates, or any entities connected to these persons, business, or organizations for services provided through Peacemakers. I acknowledge and understand that the information provided by G. Renee and ALL Peacemakers ministry workers during any level of service or sessions cannot replace or substitute the services of any professional personnel including medical, psychological, financial or legal and none of the information should be confused as such. Neither G Renee, Peacemakers Inner Healing, nor any assigned sponsors, speakers, partners, contractors or any of their affiliates will be liable for any direct, indirect, consequential, special, exemplary or other damages to the Client, Client’s family, life situations, or Client’s business including economic loss, that may result from participation in the Program or from the use or inability to use the materials, information or strategies communicated through the Program. I acknowledge and understand that the Client (person/s receiving services and or guardian), alone are responsible and accountable for the decisions, actions, and results in life, and by their participation in this Program, they agree not to attempt to hold G Renee, Peacemakers Inner Healing, or any entities connected to these persons, business, or organizations liable for any decisions, actions or results that the client may make or experience in your family, business, ministry or life due to your participation in this program at any time, under any circumstances.
I acknowledge that I have read the above Release of Liability. I acknowledge that I am signing feely and voluntarily this agreement and intend by my signature to be a complete an unconditional release of all liability to the greatest extent of the law.
*
Please Type full name for acknowledgement
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