Don Dickerman Ministries - On-Line Deliverance Form

Section 1: Personal Information* This field is required.

First Name

Last Name

Age

Phone

Father's Last Name

Your Date of Birth:

Were you the first born?:

Prior Marriages?

YESNO

Spouse Name

First Name

Last Name

Do you have children?

YESNO

Names of ChildrenPut None if needed

Father's Last Name

Mother's Maiden Name:

Are you saved?:

Where and approximately what age?:

Name of current church: (put None if needed)

How did you hear about this ministry?:

Have you been baptized?:

Participated in communion?:

Aware of ancestor involvment in any of these?:Note: It is not necessary to go into detail with any of your responses. Ask the Holy Spirit to show you any area of concern.

YESNO

From birth and your early childhood: Trauma during pregnancy by your mom or dad, divorce, words of "We shouldn't be having this child", etc.?If Yes, explain:

Early childhood fears, injuries, nightmares, see things in your room, felt evil presence?: If Yes, explain:

Any sexual abuse, or sexual embarrassment through childhood?: If Yes, explain:

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 school teacher?: If Yes, explain:

Any physical abuse from parents or others?: If Yes, explain:

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.?: 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:

Movies or TV programs that were particularly frightening to you, or specific scenes that seem to stick in your memory:

Have you participated in pre-marital sex?:

Yes

Periods of immorality?: If Yes, explain and specify ages:

Drinking and/or drug use?: If Yes, explain and specify ages:

Do you experience unusual fears?

Yes

What do you think may be the areas of demonic influence in your life?:

Problems in home?:

YESNO

Are your parent's divorced?:

Yes

If Yes, how old were you?:

Unusual feelings such as: Never really felt loved, couldn't please my father/mother, feelings of worthlessness, etc.?:

YESNO

Exposed to pornography?:

Yes

If Yes, how old were you?:

Homosexual tendencies?:

Participated in college fraternities or sororities?:

Feelings of guilt and shame?:

Hopelessness?

Fatigue without medical reason?:

Abortion?:

Difficulty in forgiving?:

Is there bitterness, anger, or unforgiveness?

If so, can you forgive?:

Do you hate yourself?:

Have you suffered from self harm?:

Do you have feelings of gloom?:?

Do you feel rejected?:

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, Native American artifacts, wiccan, etc.?:

If Yes, can you give examples?:

Ever "felt" a presence in the room?

If Yes, please explain:

Do you have difficulty in trusting others?:

If Yes, do you know why? Please explain:

Has there been a death of someone close to you?

If so, whom?:

Do you feel like you have any eating disorders?:

If Yes, do you know when they begin? Please give approximate height and weight:

Do you suffer from sleep disorders?:

If Yes, has it been recently?

If either question was Yes, please explain:

Do you have nightmares?:

If Yes, do you hear voices?

If either question was Yes, please give an example:

Have you been diagnosed by a doctor as having: (list any diagnosis, diabetes, asthma hypertension, etc.)?:

If Yes, list the diagnosis here:

Do you have inexplicable pain...no medical explanation for it?:

Any other medically defined disorder?

If Yes, please explain:

Is there a history of tuberculosis, diabetes, ulcers, cancer, heart disease, glandular problems, asthma, other in your family?:

If Yes, please explain:

Did you have imaginary friends as a child?

If Yes, what were their names:

Type a question

When attending Church or other ministries do you have "foul" thoughts, jealousies or other mental harassment?:

Do you have difficulty retaining God's Word?

Difficulty in reading it?:

Do you have migraine headaches?

Do you have any addictions?:

Were you ever diagnosed with a learning disability i.e. (A.D.D.), etc?:

Do you have a fear of death?

Have suicidal thoughts?:

Has there been a period of time in your life when you were angry with God?:

Do you have a fear of losing your mind?:

Anxiety or panic attacks?

If Yes, when did they begin?:

Do you feel incredible loneliness?

Are you plagued with doubt and unbelief?:

Do you feel inferior?

Do you have thoughts of inadequacy?:

Blasphemous thoughts?

Compulsive thoughts?

Lustful thoughts?

Are you rebellious?:

Do you daydream?

Are you a perfectionist?:

Are things seemingly always out of order?:

Do you feel the need to be in control?:

Insecurity? (On a scale of 1-10 with 10 being worst)?Insecurity? (On a scale of 1-10 with 10 being worst)?

Here are a few symptoms of demonic attack, please check any symptom that applies to you:

A compulsive desire to blaspheme God.

A revulsion against the Bible, including a desire to tear it up or destroy it.

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 behavior 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 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 reason.

Choking sensations.

Pains which seem to move around and for which there is no medical cause.

Feelings of tightness about the head or eyes.

Dizziness, blackouts, or fainting seizures.

Deep depression and despondency.

Sudden surges of violent rage, uncontrollable anger, or seething feelings of hostility.

Terrifying doubt of one's salvation even though they once knew the joy of salvation.

Seizures of panic or other fear that is terrifying.

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.

Questions and challenges to God's Word.

Sleep or eating disorders without physical cause.

Most compulsions and obsessions.

Rebellion and hatred for authority.

Bizarre terrifying thoughts that seem to come from nowhere and you cannot control them.

Fascination with the occult.

Involvement in criminal activity.

Extremely low self-image (unworthy, a failure, no good - a constant undermining of the self-identity)./li>

Constant confusion in thinking (sometimes great difficulty in remembering things).

Inability to believe (even when the person wants to).

Mocking and blasphemous thoughts against preaching/teaching of the Word of God.

Perceptual distortions - perceiving anger, hostility, in others when it doesn't really exist - seeing only judgment in the scriptures.

Horrible nightmares causing fear (often having demonic images).

Violent thoughts (suicidal, homicidal, encouraging self-abuse, etc.).

Hatred and bitterness toward others for no justifiable reason.

Tremendous hostility or fear when encountering someone involved in deliverance work.

Feelings of being watched or sensing an evil presence.

Deep depression and despondency (frequently and at significant times).

Irrational fears - panic attacks - phobias.

Irrational anger - rage.

Irrational guilt - self-condemnation to the extreme.

Desire to do what is right (inability to carry it out).

Sudden personality and attitude changes (severe contrasts - appears schizophrenic) Bi-polar disorder.

A strong aversion toward scripture reading and prayer (especially one on one).

A dark countenance (steely or hollow look in eyes - contraction of the pupils - sometimes facial features contort or change - often an inability to look at your directly.

Lying, exaggerating, or stealing compulsively (often wondering why).

Drug abuse (especially when there is demonic hallucinations).

Eating obsessions - bulimia, anorexia nervosa.

Compulsive sexual sins (especially perversions).

Irrational laughter or crying.

Irrational violence - compulsion to hurt self and/or someone else.

Sudden speaking of a language not previously known (often an ethnic language of ancestors).

Reactions to the name and blood of Jesus Christ (verbally or through body language).

Extreme restlessness (especially in a spiritual environment).

Uncontrollable cutting and mocking tongue.

Vulgar language and actions.

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).

Extreme sleepiness around spiritual things.

Demonstration of extraordinary abilities (either ESP or Telekinesis).

Voices are heard in the mind (they mock, intimidate, accuse, threaten or bargain).

Voice - refers to him/her in the third person.

Supernatural experiences - hauntings, movement or disappearance of objects, and other strange manifestations.

Seizures (too long and/or too regular).

Pain (without justifiable explanation - especially in head and/or stomach).

Blackouts.

Physical ailments can often be alleviated immediately by a command of spiritual authority (i.e. epileptic seizure, asthma attacks, various pains).

Sudden interference 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.

AdditionalComments

Please verify that you are human* This field is required.

Don Dickerman Ministries - On-Line Deliverance Form