Adult Deliverance Questionnaire V1 2024

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YOUR COMMITMENT:
The suggested donation is a minimum of $250 per person, per session, paid at the completion of this questionnaire. We do have operating costs, and therefore we ask for a Tax Deductible donation to our ministry at the end of this questionnaire.

Completion of the questionnaire and any pre or post session "homework.”

Willingness to forgive, repent, and maintain your freedom going forward, also to be honest and cooperative during your session.

Arranging for intercessors to cover you before and during your session. This is not required but is strongly recommended.

You are responsible for arrangements and cost of travel, lodging, meals, and transportation, if applicable.

Scheduling: Upon receiving your completed questionnaire, we will email a scheduling link so that you can select the date and time of your prayer session.

Note, All sessions are in-person at our offices in Colorado Springs, Colorado

INSTRUCTIONS:
Pray before filling out this questionnaire. Ask the Holy Spirit to guide you and bring critical things to your mind.

The questionnaire is lengthy and VERY personal, but every question has a purpose! Please fill in everything honestly and to the best of your ability. We are not here to sit in judgement of you, but to aid in your healing process.

Your privacy is of the utmost importance! We utilize password protected information storage, and we never share or discuss your personal information with anyone outside of our ministry team.

Jareb and Petra Nott
www.engagemin.org
office@engagemin.org
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1. Name* This field is required.
First Name
Last Name
3
2. Today's Date* This field is required.
Date
Year
Month
Day
4
3. Mailing Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
4. Physical Address (If ZOOM session for emergency purposes)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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5. Email* This field is required.
example@example.com
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6. Mobile Phone* This field is required.
Country Code
Area Code
Phone Number
8
7. What is your age?* This field is required.
9
8. Emergency Contact and Phone Number* This field is required.
Please enter emergency contact name
Please enter emergency contact phone
10
9. What is your gender?* This field is required.
11
10. Do you identify with your biological gender?* This field is required.
YESNO
12
11/12. Community information* This field is required.Hebrews 10:24 And let us consider how to stir up one another to love and good works, 25 not neglecting to meet together, as is the habit of some, but encouraging one another, and all the more as you see the Day drawing near.
Are you regularly involved with a community of believers?
Please Describe, include pastors name if applicable
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13. Marital Status* This field is required.Single | Married | Divorced | Widowed
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14. Maiden name (if applicable)
15
15. Other names by which you've been known
16
16. How did you hear about us?* This field is required.
17
17. If you were referred by your pastor/spiritual leader, list their names
18
18. What is your race or ethnicity?* This field is required.
19
19. What is your sexual orientation?* This field is required.
20
20. What is your country of origin?* This field is required.
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21. What prompted you to contact us?* This field is required.
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Ok
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22. How were you disciplined?* This field is required.
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23. Describe the predominant atmosphere in your childhood home* This field is required.Peaceful, Chaotic, Heavy, Comfortable, Strained etc.
24
24. Who raised you?* This field is required.
25
25. Were you raised in a blended family?* This field is required.
YESNO
26
26. Do you have future hopes for your life?* This field is required.
YESNO
27
27. Describe your view of God* This field is required.0 meaning Vengeful and Iron fisted 10 meaning Father of Love and Grace
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28/29. Marriage* This field is required.
How many times have you been married?
If divorced, why did the marriages end?
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30. Have any of your relationships been verbally or emotionally abusive?* This field is required.
YESNO
30
31. Were any of your relationships unhealthy or toxic?* This field is required.Manipulative, controlling, etc.
YESNO
31
32-35. Your Parents* This field is required.
Where was your father born?
Where was your mother born?
Please Select
Please Select
Yes
No
Is your mother living
Please Select
Please Select
Yes
No
Is your father living
32
36/37. Parents Continued* This field is required.
Please Select
Please Select
Yes
No
Is/Was your father a believer?
Please Select
Please Select
Yes
No
Is/Was your mother a believer?
33
38. Were you raised in a Christian home?* This field is required.
YESNO
34
39. Did you have a good relationship with your father?* This field is required.
YESNO
35
40. Did you have a good relationship with your mother?* This field is required.
YESNO
36
41. Were you raised in an alcoholic or drug dominated home?* This field is required.
YESNO
37
42. Do you have siblings?* This field is required.
YESNO
38
43. Where do you fall in the sibling line?
39
44. Briefly describe your relationship with your siblings while you were growing up.
40
45. Briefly describe your relationship with your siblings today* This field is required.
41
46. Did you grow up in a happy home?* This field is required.
YESNO
42
47. Were you a lonely child?* This field is required.
YESNO
43
48. How would you describe your family's financial situation as a child?* This field is required.
44
49. Do you give financially?* This field is required.
YESNO
45
50. Is (was) your father a perfectionist?* This field is required.
YESNO
46
51. Is (was) your mother a perfectionist?* This field is required.
YESNO
47
52. Were you raised in a verbally or physically abusive home?* This field is required.
YESNO
48
53. Were you sexually abused at home?* This field is required.
YESNO
49
54. Were you abused sexually outside of the home?* This field is required.
YESNO
50
55. Are you aware of any patterns of ungodly behaviors, accidents or infirmities in your generational history?* This field is required.
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51
56. What is your occupation?* This field is required.Note, stay at home spouse/parent, and retired are valid answers
52
57. Are you passionate and satisfied in your career?* This field is required.
YESNO
53
58. Do you now, or have you ever had a "work spouse?" * This field is required.A co-worker of the opposite sex with whom you have a close platonic relationship.
YESNO
54
59. Describe your relationship with management
55
60. Military
Were you in the Military
If so, what branch?
If Navy, or Marines, were you a Shellback or Pollywog?
56
61. Have you been verbally or emotionally abused at work?* This field is required.
YESNO
57
62. Where have you lived* This field is required.Nations, Regions
58
63. Where have you travelled?* This field is required.
59
64. Have you visited pagan temples or sacred sites?* This field is required.
60
65. Do you have any cultural souvenirs from your travels?* This field is required.
YESNO
61
66. Have you participated in any cultural or native ceremonies, rituals, rites?* This field is required.
YESNO
62
67. Were you a planned child?* This field is required.
YESNO
63
68. Were you conceived out of wedlock?* This field is required.
Yes
No
Don't Know
64
69. Were you adopted?* This field is required.
YESNO
65
70. At what age were you adopted?Leave blank if N/A
66
71. Do you know your birth parents?* This field is required.
YESNO
67
72. Were either you or your mother in trauma during her pregnancy with you, or during your birth?* This field is required.
Yes
No
Don't Know
68
73. Are you the sex that your parents wanted?* This field is required.
Yes
No
Don't Know
69
74. Are you the sex you want to be?* This field is required.
YESNO
70
75. Where were you born?* This field is required.City, State, Province, Nation
71
76. Have you accepted Jesus and the gift of salvation?* This field is required.
YESNO
72
77. Approximately what age did you receive salvation?* This field is required.
73
78. How has your life changed?* This field is required.
74
79. Tell us about your conversion* This field is required.
75
80. Were you baptized?* This field is required.
YESNO
76
81. Approximately what age were you baptized?
77
82. In what denomination were you baptized?
78
83. How is your relationship with Jesus today?* This field is required.
79
84. How does the Holy Spirit communicate with you?* This field is required.
80
85. What is your church background?* This field is required.Denominations and/or church experience?
81
86. Do you have assurance of your salvation?* This field is required.
YESNO
82
87. Have you been filled with the Holy Spirit?* This field is required.
YESNO
83
88. Describe the frequency of your personal devotion and prayer time?* This field is required.
84
89. Have you had consensual sexual contact with anyone outside of marriage?* This field is required.List first names if known
85
90/91. Have you been sexually abused or assaulted?
Please Select
Please Select
Yes
No
yes/no
Approximately when and by whom
86
92. List names of former spousesWeather living, deceased, or divorced
87
93. Have you experienced sexual encounters with demons?* This field is required.
If yes explain
88
94. Have you viewed pornography?* This field is required.Select all that apply
Yes
No
Past
Current
89
95. Have you engaged in masturbation?* This field is required.Select all that apply
Yes
No
Past
Current
90
96. Have you participated in Kama Sutra?* This field is required.Select all that apply
Yes
No
Past
Current
91
97. Have you been diagnosed with an STD?* This field is required.
YESNO
92
98. Are you easily frustrated? If yes, do you show it or bury it?* This field is required.
Yes
No
Show
Bury
93
99. Would you describe yourself as* This field is required.
Anxious
Worrier
Depressed
N/A
94
100. Have you personally ever had psychiatric counselling?* This field is required.
YESNO
95
101. Have you ever been hypnotized?* This field is required.
YESNO
96
102. Do you ever feel mentally confused?* This field is required.
YESNO
97
103. Do you daydream or have mental fantasies?* This field is required.
YESNO
98
104. Do you suffer from frequent bad dreams/nightmares?* This field is required.
YESNO
99
105. Have you ever been tempted to commit suicide?* This field is required.
YESNO
100
106. Have you ever wished to die?* This field is required.
YESNO
101
107. Have you ever received a mental health diagnosis?* This field is required.Please explain
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102
108. Have you ever been diagnosed with a behavioral disorder?* This field is required.Please explain
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103
109. To your knowledge, do you have any issues pertaining to memory loss or memory impairment?* This field is required.
YESNO
104
110. Describe the predominant atmosphere in your home* This field is required.Peaceful, chaotic, heavy, comfortable, strained etc.
105
111. Do you have in your home any symbols of idols or spirit worship such as* This field is required.
None
Buddha
Totem poles
Painted facemasks
Idol carvings
Fetish objects
Feathers
Pagan symbols
Tikis
Native art
Horoscopes
Astral travel
Lucky charms
Other
106
112. Do you practice feng shui?* This field is required.
YESNO
107
113. Do you practice smudging?* This field is required.
YESNO
108
114. Have you watched or read demonic movies, TV shows, magazines, websites, or books?* This field is required.Promoting witchcraft, horror, pagan religions, sexual content, pornography
YESNO
109
115. What type of music filled your mind prior to conversion?* This field is required.
Rock & Roll
Punk Rock
New Age
Rap
Heavy Metal
Country
Gospel/Christian
Classical
Contemporary
Jazz
Other
110
116. What type of music fills your mind now?* This field is required.
Rock & Roll
Punk Rock
New Age
Rap
Heavy Metal
Country
Gospel/Christian
Classical
Contemporary
Jazz
Other
111
117. Have you ever done any deliverance ministry or inner healing ministry on yourself?* This field is required.If yes, please give a brief description and include approximately when
112
118. Have you undergone any deliverance or inner healing sessions with another ministry?* This field is required.
113
119. Do you have any unhealthy emotional connections with any people, places, or objects?* This field is required.Unhealthy means any of the following: · Keeps you in a cycle of trauma or loss · A dependency on someone or something other than God · Hinders you from moving freely into God's direction for you · Connections that give someone other than God control over your life · Connections that keep you in anger, bitterness, fear, or depression
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114
120. My beliefs* This field is required.
I am all alone
I was a participant
I am not loved, needed, cared for, or important
No one will believe me
I don’t matter
I am going to die
I am worthless with no value
There is no way out
God has forsaken me
I do not know what to do
I was a mistake
They do not need me
I cannot trust anyone
If I tell, they will come back and hurt me
I was never liked by them because I was_________!
They are not coming back
I cannot trust church leaders
It is just a matter of time before this happens again
I am in the way; I am a burden
I am dirty, evil, shameful, perverted, because of what happened to me
He, she, they are coming back
If I let him/her/them back in my life, they will hurt me
I could never jump high enough to please him/her
I will always be hurt, damaged or broken because of what happened.
I cannot stop this
Something bad will happen if I tell, stop it, confront it
I am not acceptable
They do not need me
I am so stupid, ignorant, idiot
I am just in the way
Everything is confusing
God could never love meI was a participant
I will always be unclean, filthy
There is no good thing for me
I deserved it
I should have done something to stop it from happening
He/she/they are too strong to resist
It is never going to get any better
He/she is going to hurt me
I knew what was going to happen, yet I stayed away
I am going to die, and I cannot do anything about it
It will just happen again and again
If I trust I will die
I felt pleasure so I must have wanted it
I am too weak to resist
I have no reason to live
I allowed itIt happened because of my looks, gender, body, etc.
I cannot get away
I just want to die
I should have known better
I did not try to run away
I am overwhelmed
There is no way out
I am cheap like a slut
I was paid for services rendered
Everything is out of control
I am unimportant
I did it to him/her first
I kept going back
Not even God can help me
Why would they do this to me
I have been overlooked
I am bad, dirty, shameful, sick, nasty
The pain is too great to bear
I don’t know what is happening to me
No one ever really cares
It was all my fault
I cannot get loose
This does not make any sense
No one will be able to really love me
I should have told someone
I don’t know what to do
There are no options for me
My body parts are dirty
Doom is just around the corner
I am pulled from every direction
Nothing good will ever come of this
I will never be happy
I should have stopped them
I am too small to do anything
I should have never been born
I will never feel clean again
They are going to get me
My life is ruined
I could never be as __as he or she
115
121. Have you, your spouse, your parents, or grandparents participated in the following cults? | office code WOffice code W
Occultism
Rosicrucian
Jehovah’s Witness
Gurus
Unity
Spiritism Churches
Children of Love
Christadelphians
Scientology
Bahai
Communes
Theosophy
Children of Love
Christadelphians
Scientology
Bahai
Communes
Theosophy
Native Religions
Unification Church
Islam
Hinduism
Buddhism
Christian Science
Mormons
Other
116
122. Explain who and to what extent
117
123. Have you, your spouse, your parents or grandparents been a member of any of the following? Office Code W
Freemasons (lodges)
Odd Fellows
Rainbow Girls
Eastern Star
Ku Klux Klan
Shriners
Job's Daughters
Daughter of the Nile
Other
118
124. Explain who, what, when and to what extent
119
125. Have you ever participated in occultism of witchcraft? | Office Code W* This field is required.Office Code W
YESNO
120
126. Have you participated in any of the following? | Office Code WOffice Code W
Fortune tellers
Tarot cards
Ouija board
Seances
Mediums
Palmistry
Astrology
Color therapy
Levitation
Horoscopes
Astral travel
Lucky charms
Black magic or magick
Crystals
White magic or magick
Demon worship
Spirit guides
Automatic handwriting
Native healer
Dungeons and Dragons
New Age Movement
Witch Doctors
Voodoo/Hoodoo
Reiki
None
Other
121
127. Describe your involvement with any of the above
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128. Have you read books on occultism or witchcraft? | Office Code W* This field is required.
YESNO
123
129. Have you made any pacts with Satan? | Office Code W* This field is required.
YESNO
124
130. Do you know of any curse placed on you or your family? | Office Code W* This field is required.
YESNO
125
131. Have you participated in transcendental meditation? | Office Code W* This field is required.
YESNO
126
132. Have you been involved in Eastern religion? | Office Code W* This field is required.
YESNO
127
133. Have you practiced Yoga, Tai Chi, or Reiki? | Office Code W* This field is required.
YESNO
128
134. Have you participated in telepathy or mind control? | Office Code W* This field is required.
YESNO
129
135. Have you ever seen a demonic presence? | Office Code W* This field is required.
YESNO
130
136. Have you participated in any of the following areas | office code WOffice code W
Familiar spirits
Divination
Witchcraft
visiting mediums
Yoga
Clairvoyant
Inferiority
Mind dreaming
Spirit guides/animal guides
False prophecy
Séances
Bigotry
Racism
Low self-esteem
Peeping and muttering
Self-pity
Necromancy
Drugs, illegal or prolonged legal use
Other
131
137. Have you ever participated in any of the following areas? | office code WOffice code W
Divination
False prophecy
Fortune telling or soothsayers
Rebellion
Hypnotist-enchanter
Stargazing, zodiac, horoscopes
Acupuncture
Birth charts
Magic (Black or White)
Spiritism
Self-will
Mind control / manipulation
Warlock
Witches
Sorcerer
Wizard
Spirit guides
Vampires
Animal guides
Astral projection
Water witching
Ghosts
Lust for Power and control
Other
132
138. Have you learned martial arts? | Office Code W* This field is required.
YESNO
133
139. Have you ever had premonitions, Déjà vu, or Psychic sight? | Office Code W* This field is required.
YESNO
134
140. Do (did) either of your parents suffer from depression? | Office Code W* This field is required.
YESNO
135
141. Are you experiencing problems in any of the following areas? | office code FOffice code F
Fear
Torment – Horror
Fear of death
Anxiety
Stress
Extrovert
Depression
A desire to be hermit or recluse
Fear of saying no
Migraines
Lack of trust
Doubt
Worry
Fear of rejection
Fear of abandonment
Fear of heart attacks
Fear of authority
Fear of failure
Fear of heights
A critical spirit
Panic attacks
Unhealthy fear of God
A constant desire to be alone
Fear of spiders
Fear of animals
Fear of others
Fear of not being good enough
Other
136
142. In your Christian experience do you: | Office Code ACOffice code AC
Have trouble accepting the deity of Christ
Tend to often be in heretical teaching
Tend to gravitate toward humanistic thinking
Have trouble accepting God's forgiveness
Not believe you have an anointing on your life
Tend to have a lawlessness about you
Have trouble accepting Christ's atoning sacrifice
Seem to always be persecuted in your walk with Christ
Other
137
143. Are you currently experiencing problems in any of the following areas? | Office Code BOffice code B
Lust
Satanic interest
Spiritual deadness
Fear of death
Bitterness
Various forms of corruption
Oppression
A bound mind
My ambitions and achievements
Control over life
Religion
Spiritual blindness
Other
138
144. Have you ever used any of the following drugs? | Office Code BOffice code B
LSD
Speed
Marijuana
Cocaine
Crack
Uppers
Downers
Other Illegal street drugs
None
Other
139
145. Are you addicted to any of the following | Office Code BOffice code B
Gambling
Television
Alcohol
Smoking
Compulsive exercise
Food
Coffee
Shopping
Pornography
Sex
Drugs (Rx or illegal)
140
146. Have you ever been a member of a gang? | Office Code B* This field is required.
YESNO
141
147. Are you currently experiencing problems in any of the following areas? | Office Code DDOffice code DD
Mental illness
Ear problems
Near drowning
Crippled
Spiritual blindness or deafness
Foaming at the mouth
Alzheimer's
Excessive crying or tearing
Gnashing of teeth
Pining away
Burned
Chemical imbalance
Prostration
Suicidal
Self-mutilation
Madness
Insanity
Retardation
Senility
Schizophrenia
Seizures
Epilepsy
Pananoya
Hearing voices
Hallucinations
Palsy
Attention deficit
Eating disorders
Other
142
148. Are you currently experiencing problems in any of the following areas? | Office Code EOffice code E
Error in doctrine
False prophecy
An unsubmissive attitude
Hyper spirituality
Twisting of scripture
Unteachable spirit
Defensive / argumentative
Mix the holy with the profane
New age movement
Contentiousness
Servant to corruption
Mental confusion
Fears
Maintaining a form of godliness
Hinderance to prayer
Hinderances to hearing sermons
Hinderance to moves of the Holy Spirit
Hinderance to believing faith principles
Hinderance to bible study
Dullness of comprehension
False doctrines such as Mormonism, Catholicism, Buddhism, Hinduism, Unitarianism
Other
143
149. Are you currently experiencing problems in any of the following areas? | Office Code HPOffice code HP
Haughtiness
Religious Pride
Scornful pride
Vanity
Professional pride
Regional pride
Obstinate
National Pride
Self-righteous
Dictatorial and controlling
Manipulative
Rebellion
Overbearing or domineering
Impatience
Goddip
Rejection of God's authority
Exalted feelings
Egotistical
Rejection of man's authority
Self-deception
Contentiousness
Holier than thou attitude
Strife
Idleness
Performance orientation
Bragging and boastful attitude
Attention seeking
Interrupting others
Always right
Arrogant and smug
Other
144
150. Did either of your parents suffer from depression? | Office Code HR* This field is required.Office code HR
YESNO
145
151. Are you experiencing problems in any of the following areas? | Office Code HROffice code HR
Self-hate
Self-pity
Many regrets
A broken heart
Life's unfairness
Depression
Suicidal thoughts
Excessive mourning
Gluttony
Loneliness
Dejection
Inner hurts and a torn spirit
Discouragement
Despair
Hopelessness
Inferiority
Rejection
Insecurity
Abandonment
Low self-esteem
Insomnia
False responsibility
Suppressed emotions
Continuous sorrow and grief
146
152. Do you use Marijuana? | Office Code I* This field is required.Office code I
YESNO
147
153. List any prescription medication you currently take that alters your mental state or your behaviors (such as opioids, anti-depressants, stimulants, etc.) | Office Code I* This field is required.
148
154. Have you had any major accidents requiring medical attention? (list with age) | Office Code I* This field is required.
149
155. Have you had any near drowning experiences? | Office Code I* This field is required.
YESNO
150
156. Have you had any near-death experiences? | Office Code I* This field is required.
YESNO
151
157. Are you experiencing problems in any of the following areas? | Office Code IOffice code I
Circulatory (blood)
Respiratory (breathing)
Digestive
Endocrine (hormones)
Nervous system (sensation and movement)
Excretory (waste elimination)
Reproductive
Lymphatic
Skeletal
Muscular
Musculoskeletal (combination of muscular and skeletal)
Immune system (allergies, seasonal, food)
Chronic pain or undiagnosed issues such as migraines and fibromyalgia
Other
152
158. Please list any medical diagnosis related to the above.
153
159. Have you experienced any major illness or condition not listed above? (viral, bacterial, infections, etc.) | Office Code I* This field is required.
YESNO
154
160. Have you had any plastic surgery? If yes, describe. | Office Code I
155
161. What other surgeries have you had? | Office Code I
156
162. Have you had a blood transfusion? | Office Code I* This field is required.
YESNO
157
163. Have either your birth parents, adoptive parents, grandparents, great grandparents experienced issues with any of the following? | Office Code IOffice code I
Circulatory (blood)
Respiratory (breathing)
Digestive
Endocrine (hormones)
Nervous system (sensation and movement)
Excretory (waste elimination)
Reproductive
Lymphatic
Skeletal
Muscular
Musculoskeletal (combination of muscular and skeletal)
Immune system (allergies, seasonal, food)
Chronic pain or undiagnosed issues such as migraines and fibromyalgia
Other
158
164. Are you currently experiencing problems in any of the following areas? | Office Code JOffice code J
Jealousy
Revenge
Spite
Cruelty
Extreme competition
Causing divisions
Coveting
Selfishness
ENvy
Strife
Contentiousness
Hatred
Anger and rage
Violence
Bigotry and racism
Suppressed anger
Suppressed rage
Desire to murder
159
165. Are you currently experiencing problems in any of the following areas? | Office Code LOffice code L
Lying
Flattery
Driving zeal
Strong deception
False prophecy
Gossip
Exaggeration
False teaching
Slander
Accusations
Religious bondage
Covenant breaking
Superstitions
Profanity
Guilt
Shame
Condemnation
Melancholy nature
Self-deception
False burdens
Frenzied emotional actions
160
166. Have you participated in, or are you currently experiencing any of the following? | Office Code PWOffice code PW
Perversity
Broken spirit
Evil actions
Past abortions
Child abuse
Prostitution
Masturbation
Athiesm
A filthy mind
Sexual perversions
Doctrinal error
Twisting the word
Molestation
Incest
Rape
Date rape
Spousal rape
Pornography
Chronic worrier
Self-lover
Contentious
Foolishness
Lust
Homosexuality
Lesbianism
Vain imaginations
Rebellion
Sexual frigidity
Emotional frigidity
Effeminate spirit (men)
Masculine spirit (women)
Fornication
Adultery
161
167. Have you participated in, or are you currently experiencing any of the following? | Office Code PWOffice code PW
Addiction to entertainment
Unfaithfulness
Love of money
Excessive appetite
Excessive masturbation
Worldliness
Idolatry
Chronic dissatisfaction
Love of self
Self-reward
Addiction to sports
Addiction to television
Prostitution of spirit, soul, body
162
168. Do you have any tattoos? | Office Code PW* This field is required.
YESNO
163
169. Are you currently experiencing problems in any of the following areas? | Office Code SOffice code S
Seducing spirits
Seared conscience
Deception
Fascination with evil ways
Seducers and enticers
Fascination with evil objects
Wander from the truth
Hypocritical lies
Fascination with evil people
Attracted to false signs
Attracted to false prophets
Attracted to false wonders
Jezebel (control)
Ahab spirit (passivity)
164
170. Are you experiencing problems in any of the following areas? | Office Code DOffice code D
Death seems to lurk nearby
Disease
Suicide
Clumsiness
Fighting
Dare devil acts
Speeding
Death to ministry
Death to relationships
Death to marriage
Accidents
Random acts of violence
165
171. Are you experiencing problems in any of the following areas? | Office Code SUOffice code SU
ADD, ADHD
Blasphemer
Blind
Can't hear the word of God
Confusion
Can't stay awake in church
Distracted easily
Dizziness
Fear
Lazy
Lethargy
Mental slowness
Perversions
Anemia
Arthritis
Asthma
Circulatory problems
Chronic fatigue syndrome
Eye disorders
Hearing problems
Palpitations
Sleepiness
Sleeplessness
Terror
Torment
Unbelief
166
172. Are you experiencing problems in any of the following areas? | Office Code ROffice code R
Legalism
Pride
Holier-than-thou attitude
Ritual over relationship
Slumber
Bondage
Fear
Judgement against moves of God
Fear of what others think
Have to do and say the right thing
Condemnation of others
Unbelief
Fear of failure
Judgemental
Prideful
Self-righteous
Self-exalting
Steeped in tradition
Speaks out against moves of God
Superstition
RItual
Rigid dogma
No freedom for the gifts of the H.S.
Idol worship
Spiritually dead
Lack thriving relationship with Jesus
Intellectualism
Cannot relate to supernatural
Places God in a box
Deception
Righteousness through works
167
173. Are you experiencing problems in any of the following areas? | Office Code JZOffice code JZ
Appearing prophetic
Threatened by true prophets
Seeks favor of leaders
Seeks weakness in others
Usurps authority
Takes control
Pride
Control
Seduction with words or actions
Seeks endorsement
Manipulation
Seeks recognition
Looks for the weak link
Uses flattery
Quick to find fault
Doctrinal error
Impure motive
Seeks to lead disciples
Secretive in prayer
Controlling
Uses evil deeds to control
Sexual perversion
Financial greed
Illegal wealth building
False humility
Demonstrative spiritual actions
Occult involvement
168
174. Is there anything else you think we should know?
Huge
Large
Normal
Small
Ok
Ok
169
Please indicate if you would like to have a 15 minute phone consultation prior to your session.
No
Yes
No
170
VOLUNTARY RELEASE, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT* This field is required.Please read the following statement and sign below. In consideration for being permitted to participate in a voluntary prayer ministry, herein referred to as the “Prayer Ministry”, the undersigned, herein referred to as the “Releaser”, agrees as follows: 1. RELEASE, WAIVER, DISCHARGE AND COVENANT NOT TO SUE: Releasor and Releasor’s personal representatives, assigns, insurers, heirs, executors, administrators, spouse and next of kin, hereby releases, waives, discharges and covenants not to sue Christian Harvest International, and its directors, officers, employees, agents, volunteers as well as its successors, assigns, affiliates, subordinates, and subsidiaries, all herein referred to as the “Releasees”, from any and all liability to Releasor, and to Releasor’s personal representatives, assigns, insurer, heirs, executors, administrators, spouses and next of kin for any and all loss, damage, or cost on account of injury to the person or property or resulting in the death of Releasor, whether caused by the negligence of Releasees or otherwise with Releasor is participating in the Prayer Ministry and any other activities in connection with the Prayer Ministry. 2. ASSUMPTIOM OF RISK. Releasor understands, is aware of, and assumes all risks inherent in participating in the Prayer Ministry. These risks include but are not limited to, physical and emotional responses and reactions as a result of this prayer ministry. 3. INDEMNITY. Releasor agrees to indemnify Releasees from any liability, loss, damage or cost Releasees may incur due to the participation by Releasor in the Prayer Ministry whether caused by the negligence of Releasees or otherwise. Releasor assumes full responsibility for and risk of bodily injury, death or property damage due to the negligence of Releasees or otherwise while participating in the Prayer Ministry. Releasor expressly agrees that this Voluntary Release, Assumption of Risk and Indemnity agreement, herein referred to as “Agreement”, is intended to be as broad and inclusive as permitted by the laws of the State of Colorado and that, if any portion of this Agreement is held invalid, it is agreed that a balance, notwithstanding, continue in full legal force and effect. This Agreement contains the entire agreement between the parties in regard to the Prayer Ministry. RELEASOR REPRESENTS THAT: I HAVE CAREFULLY READ THIS AGREEMENT. I UNDERSTAND IT IS A RELEASE OF ALL CLAIMS, INCLUDING THE NEGLIGENCE OF RELEASEES. I UNDERSTAND THAT I ASSUME ALL RISKS INHERENT IN THE PRAYER MINISTRY SET FORTH IN THIS AGREEMENT. I UNDERSTAND THAT I AM INDEMNIFYING THE RELEASEES. I VOLUNTARILY SIGN MY NAME EVIDENCING MY UNDERSTANDING AND ACCPETANCE OF THE PROVISIONS OF THIS AGREEMENT.
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