HEALING I DELIVERANCE I EXORCISM
CONFIDENTIAL INTAKE QUESTIONNAIRE
PERSONAL INFORMATION
Today's Date
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Name of party in distress:
*
First Name
Last Name
Name of petitioner (if different from above):
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Best phone number to reach you.
Format: (000) 000-0000.
Other Phone Number
Home, Office, Cell
Format: (000) 000-0000.
Age
*
Your date of birth:
*
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Month
-
Day
Year
Date
Available to meet:
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Morning
Afternoon
Evenings
Marital Status
*
Never Married
Married
Divorced
Divorced and remarried
Widowed
Cohabitating
How many times have you been married?
*
Your Spouse's name:
First Name
Last Name
Were you married in the Catholic Church?
Yes
No
Are you baptized?
*
Yes
No
In what denomination?
Current religious affiliation:
*
Practicing?
*
Yes
No
If Catholic, when was the last time you went to Confession?
*
How often do you go to Confession?
Do you go to Mass on Sunday?
*
Yes
No
Children living at home:
Is there anyone else living in the same house or apartment as you?
*
Yes
No
If yes, what is their relationship to you?
Who referred you to the Diocese of Corpus Christi?
*
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CURRENT ISSUES
Do you believe you are under attack by the devil?
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Yes
No
If yes, why do you believe this?
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How would you describe these difficulties
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Severe
Moderate
Constant
Variable
How long have you suffered from these aflflictions?
*
When did they start?
*
What may have caused or triggered these difficulties?
*
Are you willing to commit to a relationship with God, developing a life of prayer, and avoid major sins to be free from the evil influencing you?
*
Yes
No
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PERSONAL HISTORY
How is your relationship with God?
*
Please describe your prayer life:
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Has this pattern of prayer changed since the onset of these difficulties?
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Yes
No
How?
Is it difficult for you to pray?
*
Yes
No
Is it difficult for you to attend church?
*
Yes
No
Is it difficult for you to touch holy water?
*
Yes
No
Is it difficult for you to touch crucifix?
*
Yes
No
Other
*
Yes
No
Do you struggle with drug/alcohol use:
*
Yes
No
Do you struggle with pornography:
*
Yes
No
Do you struggle with homosexuality/gender identity:
*
Yes
No
Do you struggle with fornication/masturbation/other:
*
Yes
No
Do you struggle with addictive behavior:
*
Yes
No
Please explain any "Yes" answers:
Do you have a devotion to any saints? Who?
*
Have you ever been involved or even dabbled with any of the following? (Please check all that apply.)
*
Ouija boards
Horoscopes
Voodoo/Santeria
Witchcraft/Brujeria
New Age
Cult Involvement
Curanderos
Seances
Psychic Powers
Fortune Tellers
Astrology
Free Masonry
Past Life Recovery
Astral Travel
Tarot Cards
Wicca
Santanism
Palm Reading
Channeling
Visited Healers
Other
If you checked any of the above, please explain it and describe the experiences.
Has anyone in your family or other blood relatives ever practiced or dabbled in occult activities or been a member of the Masonic Lodge? Please explain who and what:
*
Have you ever known anyone who is involved in witchcraft or satanism?
*
Yes
No
If yes, please explain:
Have you ever known anyone who is involved in witchcraft or satanism?
*
Yes
No
If yes, please explain:
Have you ever been sexually involved with someone who practiced witchcraft or satanism?
*
Yes
No
If yes, how long was the involvement?
Have you ever had an experience of what you might call real evil?
*
Yes
No
If yes, please describe:
Has anything ever happened to you that you were not the same afterwards?
*
Yes
No
If yes, please describe:
Has anyone ever said or done something to you that really freaked you out?
*
Yes
No
If yes, please explain:
Have you ever done or said something bad but couldn't stop yourself?
*
Yes
No
If yes, please explain:
Have people ever told you that you did or said something bad but you don't remember it?
*
Yes
No
If yes, please explain:
Who hates you and why?
*
Is is possible that you are the victim of a curse?
*
Yes
No
If yes, please explain:
Do you have any spiritual (Yin/Yang, etc.), satanic or problematic tattoos?
*
Yes
No
Has anyone involved in the occult or New Age ever given you anything?
*
Yes
No
If yes, do you still have it?
*
Yes
No
If yes, please describe it:
Which three people ( or groups of people) are most difficult for you to forgive and why?
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AVENUES OF HEALING ALREADY SOUGHT
What means of relief have you already sought? Medical? (including therapy and medication):
*
Therapeutic?
*
Religious?
*
New Age or Natural Spirituality?
*
Has anyone ever "prayed over" or "exorcized" you?
Yes
No
Have you ever read books by Gabriele Amorth, Matt Baglio, Jose Fortea or Malachi Martin, or seen movies like "The Exorcist," "The Exorcism of Emily Rose" or "The Rite"? (Please name)
*
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PERSONAL HISTORY
In general, please describe your relationship to your birth family:
*
If married, please describe your relationship to your spouse and children:
*
Please check all that apply to you:
I don't remember being physically loved as a child or being given hugs or kisses.
My parents divorced when I was a child
I had no father growing up because of death/divorce/preoccupations
Growing up I was often picked on or bullied by my peers and/or siblings.
I have suffered from an eating disorder.
I suffered terribly when I discovered that I was adopted.
I have been very unlucky, unhappy in my marriage
I had an alcoholic parent(s)/grandparent(s).
People have told me that I have low self-esteem
I have had suicidal thoughts.
Have you known someone to die by suicide? Who were they? Please describe what you saw and felt
*
As a child, did you suffer abuse from someone you should have been able to trust or from someone in my family? What kind of abuse was it (sexual, verbal, emotional)? For how long?
*
As an adult, did you suffer abuse from someone you should have been able to trust or from someone in my family? What kind of abuse was it (sexual, verbal, emotional)? For how long?
*
Have you had one or more abortions. If so how many? At what age?
*
Have you had one or more miscarriages. If so how many? At what age? Describe the impact of this on you:
*
Have you suffered a severe trauma; e.g., accident, tragedy, parents splitting up, the death of a loved one, a house fire, etc. What age? Did you readjust following the trauma? Did you experience a downward spiral after the trauma? Please describe
*
Have you attempted suicide. How many times? When? How?
*
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Medical History
Please check each applicable area.
*
Depression
Marital Problems
Drug Addictions
Eating Disorders
Grief or Loss
Sexual Problems
Loneliness
Insomnia
Restlessness
See Shadows
Despair
Cutting
Chronic Illness
Anxiety or Fear
Nightmares
Alcoholism
Low Self-esteem
Lost Job(s)
Lost Relationships
Crying
Unexplained Pain
Anger
Hear Voices
Inability to Forgive
Financial Problems
Isolation
Are you being followed?
Yes
No
What time to you go to bed?
*
Hour Minutes
AM
PM
AM/PM Option
What time do you wake up?
*
Hour Minutes
AM
PM
AM/PM Option
Have you had any major surgeries, illnesses or accidents? Please describe them and indicate how lorigago these events happened.
*
Please describe your health.
*
Are you currently under the care of a medical doctor?
*
Yes
No
If yes, please explain:
Current medications
*
Has there been any psychological or psychiatric diagnosis or treatment?
*
Yes
No
Past
*
Present
*
Current medications:
*
Has there been a history or practice of using psychotropic medications?
*
Yes
No
Past
*
Present
*
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NOTES
Submit
Should be Empty: