Request Deliverance Form

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Deliverance Request Form

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Name* This field is required.
First Name
Last Name
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Personal Information* This field is required.
Spouse's Name (Put None if needed)
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Prior Marriages?:
If so choose the number
Names of children (put None if needed)
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Email* This field is required.Please provide an email you check, as a means to contact you.
example@example.com
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Phone Number* This field is required.Give us your best phone number to contact you, please
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* This field is required.
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Were you the firstborn?
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Are you saved?
If so, where and approximately what age?
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* This field is required.
Name of current church (put None if needed)
How did you hear about this ministry?
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Have you been baptized?
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Participated in Commmunion?
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The purpose of this form is to help determine possible entry ways 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.
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Are you aware of ancestor involvement in your life?* This field is required.
Yes
No
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If Yes to ancestor involvement, please explain:Please give any information that the Holy Spirit brings to your mind (even if not in the list below). 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.
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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:
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Early childhood fears, injuries, nightmares, see things in your room, felt evil presence? If Yes, explain:
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Any sexual abuse, or sexual embarrassment through childhood? If Yes, explain:
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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:
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Any physical abuse from parents or others?: If Yes, explain:
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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:
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Please list accidents or injuries that come to your mind as being frightening to you at the time:
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Please list surgeries and approximate age:
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Movies or TV programs that were particularly frightening to you, or specific scenes that seem to stick in your memory:
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Have you participated in pre-marital sex?* This field is required.
YESNO
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Periods of immorality? If Yes, explain and specify ages:
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Drinking and/or drug use?: If Yes, explain and specify ages:
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Do you experience unusual fears?* This field is required.
Yes
No
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If Yes to unusual fears, please explain:
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What do you think may be the areas of demonic influence in your life?
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Problems in home?* This field is required.
Yes
No
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If Yes to problems in home, explain:
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Unusual feelings such as: Never really felt loved, couldn't please my father/mother, feelings of worthlessness, etc.?* This field is required.
Yes
No
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If unusual feelings, explain:
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Please Select
Please Select
Yes
No
Are your parent's divorced?
If Yes, how old were you when they divorced?
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Yes
No
Exposed to pornography?
If exposed to pornography, how old were you?
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* This field is required.
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Yes
No
Homosexual tendencies?:
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Yes
No
Participated in college fraternities or sororities?:
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Yes
No
Feelings of guilt and shame?:
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Yes
No
Hopelessness?
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Yes
No
Fatigue without medical reason?:
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Yes
No
Abortion?
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Do you have difficulty in forgiving?* This field is required.
YESNO
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Please Select
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Yes
No
Is there bitterness, anger, or unforgiveness?
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Yes
No
If so, can you forgive?
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Yes
No
Do you hate yourself?
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Yes
No
Have you suffered from self harm?
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Yes
No
Do you have feelings of gloom?
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Yes
No
Do you feel rejected?
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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.?* This field is required.
Yes
No
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If Yes to objects, can you give examples?
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Ever "felt" a presence in the room?
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Yes
No
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Yes
No
If Yes, has it been recently?:
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If first answer for "felt' is Yes, please explain what and when:
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Nightmares or Voices?
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Yes
No
Do you have nightmares?
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Yes
No
If Yes, do you hear voices?
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If either answer for "nightmares or voices" is Yes, please explain
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Have you been diagnosed by a doctor as having any diagnosis of: diabetes, asthma, hypertension, etc.?* This field is required.
Yes
No
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If Yes, list the diagnosis here:
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Do you have inexplicable pain...no medical explanation for it?* This field is required.
Yes
No
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If Yes to pain, no medical explanation, please explain
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Do you have difficulty in trusting others?* This field is required.
Yes
N0
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If trust issue, do you know why? Please explain.
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Has there been a death of someone close to you?
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Yes
No
If so, whom?
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Do you feel like you have any eating disorders?* This field is required.
Yes
No
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If Yes, to "eating disorders", do you know when they begin? Please give approximate height and weight:
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Do you suffer from sleep disorders?* This field is required.
Yes
No
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Any other medically defined disorder?* This field is required.
Yes
No
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If Yes to "medical disorder", please explain.
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Is there a history of tuberculosis, diabetes, ulcers, cancer, heart disease, glandular problems, asthma, other, in your family?* This field is required.
Yes
No
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If Yes to "tuberculosis, etc", please explain.
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Did you have imaginary friends as a child?* This field is required.
Yes
No
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If yes to "imaginary firends"
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When attending Church or other ministries do you have "foul" thoughts, jealousies or other mental harassment?* This field is required.
YESNO
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* This field is required.
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Yes
No
Do you have difficulty reading God's Word?
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Yes
No
Difficulty retaining God's Word?
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Yes
No
Do you have migraine headaches?
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Yes
No
Do you have any addictions?
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Yes
No
Were you ever diagnosed with a learning disability i.e. (A.D.D.), etc?:
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Please Select
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Yes
No
Do you have a fear of death?
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Yes
No
Have suicidal thoughts?
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Yes
No
Have you been or are you now angry with God?
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Yes
No
Do you have a fear of losing your mind?
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Yes
No
Anxiety or panic attacks?
If so, when did they begin?
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Do you feel incredible loneliness?* This field is required.
YESNO
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* This field is required.
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Yes
No
Are you plagued with doubt and unbelief?
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Yes
No
Do you feel inferior?
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Yes
No
Do you have thoughts of inadequacy?
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Yes
No
Do you have obsessive thoughts?
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Yes
No
Blasphemous thoughts?
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Yes
No
Compulsive Thoughts?
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* This field is required.
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Yes
No
Lustful Thoughts?
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Yes
No
Do you daydream?
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Yes
No
Are you a perfectionist?
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Yes
No
Are things seemingly always out of order?
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Yes
No
Do you feel the need to be in control?
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Yes
No
Are you rebellious?
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Insecurity? (On a scale of 1-10 with 10 being worst)? Insecurity Number please, then explanation for your choice of number.* This field is required.
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Here are a few symptoms of demonic attack, please check any symptom that applies to you:
01. A compulsive desire to blaspheme God.
02. A revulsion against the Bible, including a desire to tear it up or destroy it.
03. Compulsive thoughts of suicide or murder.
04. Deep feelings of bitterness and hatred toward others without reason? Examples - Jews, other races, the church, strong Christian leaders. Please check the box if Holy Spirit brings anything to mind.
05. Any compulsive temptations which seek to force you to thoughts or behavior which you truly do not want to do or think.
06. Compulsive desires to tear other people down, even if it means lying to do so. Vicious cutting by the tongue.
07. Terrifying feelings of guilt even after honest confession is made to the Lord.
08. Certain physical symptoms which may appear suddenly or leave quickly and there are no physical or physiological reason. Check any of the following A,B,C,D which are symptoms.
A. ---- Choking sensations.
B. ---- Pains which seem to move around and for which there is no medical cause.
C. ---- Feelings of tightness about the head or eyes.
D. ---- Dizziness, blackouts, or fainting seizures.
09. Deep depression and despondency.
10. Sudden surges of violent rage, uncontrollable anger, or seething feelings of hostility.
11. Terrifying doubt of your salvation even though you once knew the joy of salvation.
12. Seizures of panic or other fear that is terrifying.
13. Dreams or nightmares that are of a horrific nature and often ...recurring. Clairvoyant dreams that may even come true are most often demonic.
14. Abnormal or perverted sexual desires.
15. Questions and challenges to God's Word.
16. Sleep or eating disorders without physical cause.
17.Most compulsions and obsessions.
18. Rebellion and hatred for authority.
19. Bizarre terrifying thoughts that seem to come from nowhere and you cannot control them.
20. Fascination with the occult.
21. Involvement in criminal activity.
22. Extremely low self-image (unworthy, a failure, no good - a constant undermining of the self-identity)
23. Constant confusion in thinking (sometimes great difficulty in remembering things).
24. Inability to believe (even when the person wants to).
25. Mocking and blasphemous thoughts against preaching/teaching of the Word of God.
26. Perceptual distortions - perceiving anger, hostility, in others when it doesn't really exist - seeing only judgment in the scriptures.
27. Horrible nightmares causing fear (often having demonic images).
28. Violent thoughts (suicidal, homicidal, encouraging self-abuse, etc.).
29. Hatred and bitterness toward others for no justifiable reason.
30. Tremendous hostility or fear when encountering someone involved in deliverance work.
31. Feelings of being watched or sensing an evil presence.
32. Deep depression and despondency (frequently and at significant times).
33. Irrational fears - panic attacks - phobias.
34. Irrational anger - rage
35. Irrational guilt - self-condemnation to the extreme
36. Desire to do what is right (inability to carry it out).
37. Sudden personality and attitude changes (severe contrasts - appears schizophrenic) Bi-polar disorder.
38. A strong aversion toward scripture reading and prayer (especially one on one).
39. 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.
40. Lying, exaggerating, or stealing compulsively (often wondering why).
41. Drug abuse (especially when there is demonic hallucinations).
42. Eating obsessions - bulimia, anorexia nervosa.
43. Compulsive sexual sins (especially perversions).
44. Irrational laughter or crying.
45. Irrational violence - compulsion to hurt self and/or someone else.
46. Sudden speaking of a language not previously known (often an ethnic language of ancestors).
47. Reactions to the name and blood of Jesus Christ (verbally or through body language).
48. Extreme restlessness (especially in a spiritual environment).
49. Uncontrollable cutting and mocking tongue.
50. Vulgar language and actions.
51. 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).
52. Extreme sleepiness around spiritual things.
53. Demonstration of extraordinary abilities (either ESP or Telekinesis).
54. Voices are heard in the mind (they mock, intimidate, accuse, threaten or bargain).
55. Voice - refers to him/her in the third person.
56. Supernatural experiences - hauntings, movement or disappearance of objects, and other strange manifestations.
57. Seizures (too long and/or too regular).
58. Pain (without justifiable explanation - especially in head and/or stomach).
59. Blackouts.
60. Physical ailments can often be alleviated immediately by a command of spiritual authority (i.e. epileptic seizure, asthma attacks, various pains).
61. 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.
See note below:
A few of these symptoms may not indicate demonic oppression...but these are very common symptoms for those under demonic attack.. After all there is really nothing to lose by doing so, except one's pride. When in doubt ... cast them out!
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Additional Comments
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There is something you can do to help bring about your freedom. We ask that you deal with these issues before coming for deliverance. Pray the prayers below in green.

           In order for the deliverance to be successful there can be NO unforgiveness in your life. Unforgiveness is legal permission for demons to torment believers: Matthew 18:23-35. Do not neglect the area of forgiveness for yourself. You must also forgive yourself in order to be free. A typical prayer might be as follows:

           “Father, because You have forgiven me I choose to forgive others, everyone who has hurt me, lied to me or disappointed me, I forgive. I confess unforgiveness as sin and repent of it. I receive Your forgiveness and apply it my life by forgiving myself. Thank You for Your grace and mercy in Jesus Name. Amen.”

           If there was ever any involvement (however innocent), in Satanic activities, witchcraft, cults or occultic activities they must be renounced. Typical prayer:

           “Father, I denounce any bond, or agreement I ever made with Satan and the kingdom of darkness. I know there can be no valid contract with a liar and I renounce any words, oaths or pledges made to Satan and I choose to be totally free from them. I choose to be cleansed from any ties with Satan in Jesus Name. Amen.”

           Sexual relationships outside of marriage…are called “Soul Ties” and each one could be an entry point for demon spirits. The ties must be broken by confessing them as sin and choosing to be free from them. I will include a prayer you can pray. It would be best if you could do so by denouncing each one by name, do the best you can with that. The deliverance process involves canceling permission of evil spirits to be in our life. This prayer and renunciation will cancel consent that was granted through soul ties. The prayer can be something like this:

          “Father, I confess the sin of sexual relations outside of marriage. I renounce that sinful activity in Jesus’ Name. I call back that part of me that was given to another, and I refuse that part of another that may have come to me. I denounce soul ties with and choose to be free in Jesus Christ’ Name. Amen”
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Prior to your Deliverance Session in our office, it will be necessary to sign a release for Don Dickerman Ministries. A copy of it for viewing and download can be found here:

DDM Deliverance Release Form
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Please acknowledge you have had the opportunity to view the DDM Deliverance Release Form. If you cannot check YES, please click PREVIOUS (or back arrow) to go back and view it.* This field is required.
YESNO
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We thank you for your trust in Don Dickerman Ministries. Your information is strictly confidential. We will be in touch as soon as we are able. Our office phone number is (817) 581-8860. Our email is don@dondickerman.com

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