The Defining Place Spiritual Inventory & Intake Form

  • Spiritual Inventory & Intake Form

  • All answers are given willfully and not under any pressure. We do not diagnose or treat mental illness. We do not make any recommendations regarding medications. We are strictly a Christian ministry and offer prayer ministry to free people from the influence of demonic spirits. We are mandatory reporters. While not required to receive ministry, there is a recommended donation of $200 per session because of the time invested.

    • Personal Information 
    • Date
       - -
    • Format: (000) 000-0000.

    • Section 1 of 26

    • Preferred Meeting Times 
    • If possible these are my preferred meeting times:

    • Section 2 of 26

    • SPIRITUAL INFORMATION 
    • 1. Have you made a salvation confession that Jesus Christ is your Lord?*
    • 3. Which member of the Holy Trinity do you connect with most?
    • 3. Which member of the Holy Trinity do you least connect with?

    • Section 3 of 26

    • FAMILY HISTORY 
    • Marital Status?
    • Children?
    • Rows

    • Section 4 of 26

    • HISTORY RELATED TO ABUSE 

    • If you have dealt with abuse in the past, please put X in any box that applies to you. Please briefly explain in the space below

    • What kind of abuse have you experienced?
    • Would others say you have been abused in any way?
    • Would anyone say they have been abused by you in any way?

    • Section 5 of 26

    • HISTORY OF ABUSES, ACCIDENTS, TRAUMAS, ABANDONMENTS, OR VIOLENCE 

    • 1. List any episodes of abuse, trauma, major accidents, or any other events that deeply affected you.

    • Section 6 of 26

    • HISTORY RELATED TO ADDICTIONS 
    • Please mark all that apply to you. If some of these were related to your family, indicate that in the space below.

    • Section 7 of 26

    • HISTORY RELATED TO DEPRESSION & MENTAL HEALTH 
    • Please indicate if you or your family have dealt with or are currently dealing with mental health issues byplacing an ‘X’ in the applicable box. Use the lines below to provide a brief explanation
    • Have you seen?

    • Section 8 of 26

    • GRIEF & LOSS 

    • Section 9 of 26

    • Gifts, Powers, Prophecies, Curses 
    • Perspectives Concerning Your Life 

    • Section 10 of 26

    • SECRET SOCIETY, FRATERNITY, SORORITY, AMISH CHURCH, OTHER CHURCH MEMBERSHIPS, ETC. 
    • Are you or a family member currently a member of a secret society, fraternity, sorority, or church?
    • Were you or a family member a member of a secret society, fraternity, sorority, or church?
    • Were you or a family member dedicated into a secret society, fraternity, sorority, or church?
    • Were you or a family member baptized into a secret society, fraternity, sorority, or church?

    • Section 11 of 26

  • Please indicate any religious, occult, or new age practices you or your family has participated in. Please explain below.

  • Section 12 of 26

    • FAMILY PATTERNS 
    • Please mark all family patterns that apply to you.

    • Section 13 of 26

    • FEARS, NIGHTMARES, & NIGHT TERRORS 
    • Please put an X in the box(es) that apply to you.

    • Section 14 of 26

    • IDENTITY RELATED / NICKNAMES / ONLINE PROFILES 
    • How would you describe yourself? Please indicate all that you think apply to you.

    • Section 15 of 26

    • LIES 
    • Please Indicate any of the lies or negative self talk that you’ve struggled with:

    • Section 16 of 26

    • HISTORY RELATED TO OCCULT 
    • Please indicate any religious, occult, or new age practices you or your family has participated in. Please explain below.

    • Section 18 of 26

    • OCCULT SYMBOLS / OBJECTS OF IDOL WORSHIP 
    • Amulets Buddha Caduceus Carvings Fetish Objects or Feathers Gargoyles Masks

    • Section 17 of 26

    • Books, Shows, & Media that were Occult, Horror, Sexual, Etc Related 

    • Section 19 of 26

    • PHYSICAL HEALTH, ILLNESSES, & DIAGNOSES ISSUES 
    • Please mark any that apply to you or your family.

    • Section 20 of 26

    • HISTORY RELATED TO ACCEPTANCE / REJECTION 
    • Rows
    • SEXUAL HISTORY (GIVEN BY PERMISSION) 

    • Sexual History (given by permission)

    • Please put X in any box that applies to you.
    • Age of your earliest erotic thought?
    • Do you ever see sexual images while being in a spiritual setting?
    • Do you ever experience a dark bullying presence at night or see things in your room?
    • Have you ever experienced sleep paralysis inability to move or speak / a pressure on your chest?
    • Have you experienced waking up feeling as though someone was having sex with you, but no one was?
    • Have you had sex outside of marriage?
    • TATTOOS 

    • Section 21 of 26

    • FAMILY RELATIONSHIPS - FATHER 

    • FAMILY RELATIONSHIPS - FATHER

      Please answer the following questions to the best of your ability. When given a choice, please designate the most accurate answer(s).
    • Were you and your father friends?
    • Were you and your father friends?
    • My father was... (check all that applied while growing up)
    • Was he proud of you?
    • Was he disappointed with you?
    • Did he discipline or correct you?
    • Were you able to easily connect with him while growing up? Please explain
    • Did he hurt your feelings in any way not discussed above?

    • Section 22 of 26

    • FAMILY RELATIONSHIPS - MOTHER 

    • FAMILY RELATIONSHIPS - MOTHER

      Please answer the following questions to the best of your ability. When given a choice, please designate the most accurate answer(s).
    • Were you and your mother friends?
    • Were you and your mother friends?
    • My mother was... (check all that applied while growing up)
    • Was she proud of you?
    • Was she disappointed with you?
    • Did she discipline or correct you?
    • Were you able to easily connect with her while growing up?
    • Did she hurt your feelings in any way not discussed above?

    • Section 23 of 26

  • FAMILY RELATIONSHIPS - SIBLINGS

    Please answer the following questions to the best of your ability. When given a choice, please designate the most accurate answer(s).
  • Were you and your siblings friends?
  • Are you and your siblings currently friends?
  • My siblings were... (check all that applied while growing up)
  • Do you feel like you had to compete with them?
  • Were you able to easily connect with them while growing up?
  • Did they hurt your feelings in any way not discussed above?

  • Section 24 of 26

    • POSSIBLE DEMONIC ACTIVITY OR MANIFESTATIONS 
    • Please put X in any box that applies to you.

    • Section 25 of 26

    • FINAL THOUGHTS 

    • Section 26 of 26

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