Inner Healing and Deliverance Ministry Intake Form
Please complete all information to the best of your knowledge and as honestly as possible.
Name
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First Name
Last Name
Email
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example@example.com
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Age
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Marital Status (married (how many times) single, separated, divorced?):
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If relevant, tell us about your spouse (believer, unbeliever, good relationship, etc). Type N/A if not applicable
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Have you ever had any inner healing or deliverance ministry before? What kind and what was that experience like?
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Why do you believe you need ministry?
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Please share your Cultural and Ethnic Background
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How would you describe the quality and state of your life at the moment?
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When did you first decide to follow Jesus?
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Have you been water baptized? When?
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Have you been baptized in the Spirit? When?
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Is Jesus the Lord of your life?
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How healthy do you feel that your relationship with God is?
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Describe your prayer life?
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Do you believe God loves you?
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How often do you read the Bible?
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Do you feel able to connect with all parts of the Godhead: Father, Jesus and Holy Spirit? Do you feel more comfortable with one? Do you struggle with one more than the others?
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Do you feel like anything blocks or hinders your relationship with God?
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What has your experience with The Church been like in your life?
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Do you belong to a Christian community now?
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What has been your experience with Christian leaders?
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Have you been ordained? By who and as what?
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Are you a member of a denomination? Which one?
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Do you feel that you have been restricted in some way by leaders in your life, past or present?
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Have you ever been a victim of spiritual abuse? Explain:
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Are you or have you ever been a leader among the body vocationally? (whether five fold, staff member, ministry leader, team/dept leader, missionary etc)
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Do you struggle with doubt or unbelief?
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Tell us about your father and your relationship with him:
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Tell us about your mother and your relationship with her:
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If you have stepparents, tell us about your relationship with them:
Please tell us about your relationship with any grandparents. Also were/are your parents/grandparents Christians? If not, what is their spiritual history?
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Were you wanted as a baby?
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Were you conceived outside of wedlock?
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Were you adopted?
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Were you the sex desired by your parents?
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What was your life like in your family as a child?
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Did you feel seen, heard and able to be yourself in your family? Explain
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Do you believe your family is cursed in some way? Any legends or patterns? (Examples: miscarriages, same cancer, marriages never lasting past certain points, etc)? Explain
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Has there been any type of repetitive or dysfunctional situations or experiences that seem to happen in your wider family often? (molestation, physical accidents, sicknesses, addictions, etc) Explain
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How would you describe your capacity for stress, emotional pain? (I can handle a lot, I feel fragile, etc)
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What range of emotional expression is normal for you? (limited to just a few- anger, sadness, happiness to wide- I'm able to display a wide range of emotions that I can identify and believe are appropriate for the situation.)
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Do you feel comfortable with displaying outward emotions like crying?
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What about when others display emotion? How does it make you feel?
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How would you describe the health of your relationships? (wide and deep, wide, a few close, I struggle to form or keep friendships)
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How connected is your value or self-worth to your accomplishments?
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Do you feel comfortable resting or is rest a challenge?
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Is there anyone that you're afraid of?
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Have you had a hard time overcoming grief in any way? Explain:
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Have you had any mental illness diagnosis?
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Have you ever gone by a different name or identity?
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Check all that apply:
Fear
Anxiety
Panic Attacks
Control
Self Harm
Hatred (towards self and/or others)
Depression
Shame
Obsessive Behaviors
Addictive Personality
Insecurity
Worthlessness
Bitterness
Extreme Shyness
Jealousy
Rage
Desiring revenge
Other
Expound on any of the above as needed:
Please explain the state of your mental health in your own words:
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Please explain the state of your physical health in your own words:
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Please share any relevant emotional or physical trauma by age: 0-5 years
6-10 years
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11-15 years
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16-20 years
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21+ years
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Do you have any periods of time that you can't remember? Which ones?
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Have you been subjected to any demonic rituals to your knowledge?
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Have you experienced issues with fertility?
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Is there anyone that you hate? Why?
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Is there anyone that you've had a hard time forgiving? What happened?
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Any tattoos? List them and why you got them:
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Any current or previous addictions?
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Are there financial patterns or cycles in your life that concern you?
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Have you had an abortion (mother or father) or have you pressured or paid for someone else to have one?
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Have you ever been the victim of any type of traumatic physical abuse?
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Have you ever been the perpetrator of abuse towards others?
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Have you been sexually abused in any way? By who, when and what happened?
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Have you had sexual partners outside of your spouse at any point?
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Have you ever been sexually involved with a person involved in new age, witchcraft or the occult?
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Have you ever been involved in new age, witchcraft or the occult? If yes, actively training or passive interest? Please explain.
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Have you been a teacher or guide of yoga or other types of embodiment practices?
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Were any family members that you're aware of involved in witchcraft or the occult?
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Do you currently live with a person involved in witchcraft/occult?
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Do you currently own objects or heirlooms used in witchcraft/occult?
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Have you had any out of body experiences?
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Have you ever been involved in another religion in any way?
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Have you ever had a disassociated fractured parts (alters)/inner child present itself?
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Explain any criminal activity in your past that you're willing to share?
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Have you ever pledged a sorority or fraternity?
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Is anyone in your ancestry involved in any Masonic org, organized crime or any other secret society or cult? (This includes orgs like Knights Templar, Eastern stars, Jobs Daughters or childhood groups like Brownies or Boy Scouts.)
Are you a survivor of SRA (satanic ritual abuse) or any type of consistent ritualistic abuse or programming? Please explain in detail.
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Explain any types of spiritual experiences that you've had. Things such as: re-occurring evil dreams, sudden dizziness/confusion, night terrors, sleep paralysis, hearing voices, seeing/encountering demons, feeling terrorized by demons, sexual experiences with demons, encounters with unknown beings, experiences through the use of substances.
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Is there anything else that you would like to share that you feel could help us minister to you better?
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Submit
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