Deliverance Ministry Intake Form

Deliverance Ministry Intake Form

Please complete this confidential form to help us understand your personal and spiritual background for your upcoming deliverance session. All information will be kept strictly confidential.
- Full Name*
  
  First NameLast Name
- Spouse's Name (if applicable)
  
  First NameLast Name
- Address*
  
  Street Address
  
  Street Address Line 2
  CityState / ProvincePostal / Zip Code
- Phone Number*
  Please enter a valid phone number.
- Email Address*
  example@example.com
- Date of Intake*
  
  MonthDayYear
  Date
- Marital Status*
  
  SingleMarriedDivorcedWidowedSeparatedOther
- Number of Prior Marriages (if any)
- Children (Please list names and ages, or enter 'N/A' if not applicable)
- Birth Order (e.g., oldest, middle, youngest, only child)
- Are you a Born-Again Christian?*
  
  YesNoNot sure
- If yes, at what age and where did you experience conversion? (or enter 'N/A')
- Current church affiliation (if any)
- How often do you attend church services?
- Preferred Appointment Date and Time*
- Best Days and Times to Meet (Please specify, or enter 'N/A')
- Describe your family's spiritual background (parents, grandparents, etc.). Enter 'N/A' if not applicable.
- Are you aware of any generational influences (e.g., patterns of addiction, abuse, occult involvement) in your family?*
  
  YesNoNot sure
- If yes, please explain or list. Enter 'N/A' if not applicable.
- Have you experienced any significant childhood traumas? (e.g., loss, accidents, abuse)*
  
  YesNo
- If yes, please describe the experience(s) or enter 'N/A'.
- Have you experienced any form of abuse?
  
  NonePhysical abuseSexual abuseEmotional abuseOther
- If abuse occurred, please provide details or enter 'N/A'.
- Have you been involved in any occult or supernatural activities (e.g., witchcraft, séances, fortune-telling, etc.)?*
  
  YesNo
- If yes, please explain or list. Enter 'N/A' if not applicable.
- Have you had any supernatural experiences (e.g., visions, voices, unexplained events)?*
  
  YesNo
- If yes, please describe or enter 'N/A'.
- Have you engaged in any of the following behaviors? (Check all that apply)
  
  Premarital sexImmoralitySubstance use (alcohol, drugs, etc.)Exposure to pornographyAbortionNone of the aboveOther
- If any selected, please provide details or enter 'N/A'.
- Do you struggle with any of the following? (Check all that apply)
  
  Fears or phobiasFeelings of guilt or shameHopelessness or depressionFatigue or exhaustionDifficulty forgivingNone of the aboveOther
- If any selected, please provide details or enter 'N/A'.
- Do you believe you may be under demonic influence or oppression?
  
  YesNoNot sure
- If yes or not sure, please explain or describe your experiences. Enter 'N/A' if not applicable.
- Have you or your family experienced any of the following? (Check all that apply)
  
  Frequent accidentsMajor surgeriesSerious illnessesUnusual deathsNone of the aboveOther
- If any selected, please provide details or enter 'N/A'.
- Have you been exposed to frightening or violent media (movies, games, etc.)?
  
  YesNo
- If yes, please list or describe, or enter 'N/A'.
- Confidentiality Statement: All information provided in this form will be kept strictly confidential and used only for the purpose of your deliverance session.
- Liability Release: By signing below, you acknowledge that you have provided this information voluntarily and understand that the ministry is not liable for any outcomes related to the deliverance session.
- Signature (Required)*
  
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