Inner Healing & Deliverance Intake Form
All information is held confidential. At no given point is information disclosed or shared without client’s written consent.
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Format: (000) 000-0000.
E-mail
example@example.com
Where are you located?
Street Address
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Afghanistan
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Married
Please Select
Yes
No
Prior Marriages
Please Select
Yes
No
If yes, how many?
Please Select
0
1
2
3+
Children?
Please Select
Yes
No
Were you the firstborn?
Please Select
Yes
No
Are you a born again Bible believing Christian?
Please Select
Yes
No
Not Sure
At what age did you get born again and where?
Are you filled with the Holy Spirit?
Please Select
Yes
No
Not Sure
What age were you filled with the Holy Spirit?
What is the makeup of your spiritual experience? Check all that apply, if any.
Roman Catholic
Jehovah Witnesses
Mormonism
Islam
Extreme Pentecostalism
Gangs (bloods/Latin Kings, etc...)
Hypnosis
Judaism
Church of Christ
Iglesia de mita
Iglesia universal
New Age/Law of Attraction/Principles of Money/Quimby Teachings
Black Hebrew Israelite
Free Masonry
Buddhism
Yoga/meditation
Yuroba/African spirituality/Santeria/voodoo
Sevent Day Adventism
None of the Above
Please explain if you did not see yours.
The purpose of this form is to help determine possible entryways for evil spirits...obviously, generational/ancestral permission as forewarned in Exodus 20:5 is a possibility in anyone's life. There are 30 ancestors in your history that could have passed a spirit on to you, likely, you only know about your parents and each of their two parents. Please give any information that the Holy Spirit brings to your mind. Examples would be involvement with the occult, sexual perversion, alcoholism, depression or mental disorders, lots of divorce, adultery, anger, criminal activity, births out of wedlock, involvement in groups such as Masonry, Eastern Star, Rainbow Girls, Oddfellows and Rebecca Lodge, secret societies etc.
I acknowledge this and wish to continue.
Are you aware of any ancestor involvement in any of the previously listed?
Please Select
Yes
No
Unknown
If yes, explain.
Note: It is not necessary to go into great detail with any of your responses. Ask the Holy Spirit to show you any area of concern.
I acknowledge this and wish to continue.
From birth and your 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," etc.?
Please Select
Yes
No
Do you recall any early childhood fears, injuries, nightmares? Do you remember seeing things in your room or feeling an evil presence? Do you recall any encounters of a supernatural kind?
Please Select
Yes
No
If yes, explain.
Do you recall any spoken words from parents, or others that were condemnation: "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.; embarrassing or humiliating experiences at school or from a school teacher?
Please Select
Yes
No
If yes, explain.
Any physical abuse from parents or others?
Please Select
Yes
No
Involvement (however innocently it may have been) with Ouija Boards, Magic 8 Ball, levitation games, seances, fortune tellers, tarot cards, astrology, horoscopes, fascination with books about magic, physics seers, Harry Potter books, Pokemon cards, etc.?
Please Select
Yes
No
If yes, explain.
Please list accidents or injuries that come to your mind as being frightening to you at the time:
Please list surgeries and approximate age:
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Periods of, or habitual immorality? (including pornography, sexual fantasy, promiscuity, etc.) Explain below, please.
Drinking and/or drug use? Explain please.
Do you experience unusual fears? Explain please.
Are you often fed during your sleep and/or dreams?
Please Select
Yes
No
If so, explain please...
Do things appear before you that others do not see, but is frightening? If yes, explain
Do you hear spirits talking to you and/or accusing, fussing, and/or threatening you? If yes, explain.
Are (or were) there any significant problems in the home growing up? If yes, explain.
Are your parents divorced? If yes, how old were you when this happened?
Homosexual tendencies?
Please Select
Yes
No
Participated in class fraternities or sororities?
Please Select
Yes
No
Feelings of guilt or shame?
Please Select
Yes
No
Hopelessness?
Please Select
Yes
No
Is there anyone or an organization you struggle to forgive? If yes, please explain.
Do you have any objects in your home or possession that relate to ungodliness or cults, this would include new age religions, such as books about eastern deities, crystals, heavy metal music, Emo music, Secular music, Native American/African artifacts, Items connected with other religions or rituals, Wiccan or other occult items, etc.? If yes, explain.
Have you ever "felt" a presence in the room? If yes, explain if possible.
Do you have nightmares?
Please Select
Yes
No
Not often
Have you been diagnosed by a doctor as having: (list any diagnosis, diabetes, asthma, hypertension, etc.)
Please Select
Yes
No
Do you have inexplicable pain...no medical explanation for it? If yes, explain please.
Do you have difficulty in trusting others? If yes, please explain.
Do you suffer from sleep disorders? If yes explain.
Any other medically defined disorder? If yes explain, please.
The Bible says “death & life are in the power of the tongue” word curses occur when a person of authority pronounces a curse or negative words over your life! (Example: you’re good for nothing, etc…) Joshua 6:26 “At that time Joshua invoked this CURSE: "May the curse of the LORD fall on anyone who tries to rebuild the town of Jericho. At the cost of his firstborn son, he will lay its foundation. At the cost of his youngest son, he will set up its gates." Have There Been Word Curses Spoken Over Your Life? If yes, please explain.
Do you have blasphemous thoughts?
Please Select
Yes
No
Do you have lustful thoughts?
Please Select
Yes
No
Do you have these symptoms? Check all that apply.
A compulsive desire to blaspheme God. (Hate towards Jesus and/or the Bible)
Compulsive thoughts of suicide or murder
Deep feelings of bitterness and hatred toward others without reason: Jews, other races, the church, strong Christian leaders.
Any compulsive temptations, which seek to force you to thoughts or behaviors which you truly do not want to do or think.
Compulsive desires to tear other people down, even if it means lying to do so. Vicious cutting down of others by the tongue.
Terrifying feelings of guilt even after honest confession is made to the Lord
Certain physical symptoms which may appear suddenly or leave quickly and there are no physical or physiological reasons
Choking sensations
Pains that seem to move around and for which there is no medical cause
Dizziness, blackouts, or fainting seizures
Feelings of tightness about the head or eyes
Terrifying doubt of one's salvation even though they once knew the joy of salvation
Dreams or nightmares that are of a horrific nature and often recurring. Clairvoyant dreams that may even come true are most often demonic
Abnormal or perverted sexual desires
Sleeping or eating disorders without physical cause
Rebellion and hatred for authority
Bizarre terrifying thoughts that seem to come from nowhere and you cannot control them
Extremely low self-image (unworthy, a failure, no good--a constant undermining of the self-identity)
Irrational fears--panic attacks--phobias
A dark countenance (steely or hollow look in eyes--contraction/dilation of the pupils--sometimes facial features contort or change--often an inability to look at others directly
Irrational laughter or crying
Extreme restlessness (especially in a spiritual environment)
Uncontrollable cutting and mocking tongue
Loss of time (from minutes to hours--ending up someplace, not knowing how you got there--regularly doing things of which there is no memory)
Supernatural experiences--hauntings, movement or disappearance of objects, and other strange manifestations
Seizures (too long and/or too regular)
Sudden interferences with bodily functions (temporary)--buzzing in ears, inability to speak or hear, sudden severe headache, hypersensitivity in hearing or touch, sudden chills or overwhelming heat in body, numbness in arms or legs, temporary paralysis
Can speak in an unknown language at times, or chant
None of the above
Are you currently on any medication and/or mental health services? If yes, please explain.
What made you decide, "right now", you must be free?
I hereby acknowledge and affirm that all answers given by myself in response to the questions in this form are voluntarily submitted and that the information is true to the best of my knowledge. I hereby release, indemnify and forever hold harmless AIM Church and its agents, staff, employees and volunteers of any damages, real or perceptual, arising from personal ministry in connection with the information submitted herein.
I acknowledge and consent
Your acknowledgement of this serves as your consent and signature.
I acknowledge and wish to continue
This form was completed within my own free will. I was sober, and able to make an informed decision.
Please Select
Yes and I consent
No
I need my guardian present which is? Please explain.
Have you been baptized in water?
Please Select
Yes
No
Did you understand that your water baptism was a "death/burial/resurrection" spoken of in Romans Chapter 6?
Do You Understand That the Decision to be Baptized in Water Must be Made by the Person Getting Baptized? Baby/Child Baptisms Do Not Count.
Please Select
Yes
No
Please understand if on video call, that there may be more than one person on your video call sessions. Our team continually has people being trained, as well as other ministers, sit in as prayer support on these sessions.
I understand
Both in-person and video call sessions are recorded. The recordings of these sessions remain completely confidential and are never shown to a single person unless your permission is given to do so.
I understand
After submitting your form, our team will reach out to you. Sessions typically take anywhere from 2 to 3 hours. Inner healing and deliverance will take place in your session as Holy Spirit leads. You will be able to choose between an in-person appointment or an appointment done over video call. Donations are welcome, but no required fees.
I understand and wish to continue
AIM Church offers various resources for those wanting to be equipped and empowered to operate in inner healing and deliverance, so make sure to look around the site. Thank you so much for partnering with what God is doing in and through AIM Church! Much blessings!
I understand and wish to continue
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