Freedom Prayer Intake Form

Family History
Father
Was your father married to your mother?
Is your father still living?
How old was he when he passed away and why did he pass?
Is your father in good health?
Describe your current relationship with your father
What was your relationship with him like growing up?
What was your father's relationship like with your mother?
What was his relationship like with the children in the family?
Are there any genetic diseases in your father's family that you know of?
Mother
Was your mother married to your father?
Is your mother still living?
How old was she when she passed away and why did she pass?
Is your mother in good health?
Describe your current relationship with your mother
What was your relationship with her like when you were growing up?
What was her relationship with your father like when you were growing up?
What was her relationship like with the children of the family?
Are there any genetic diseases in your mother's family that you know of?
Your Siblings
Please list your siblings by first name and age (also indicate those who were adopted and list those that are step, miscarried, aborted, and deceased)
What is your relationship like with your siblings? What was it like when you were growing up?
Grandparents
What do you know about them?
Part 4 of 7

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The Occult-

Adapted from Christian Healing Ministries, Inc. School of Healing Prayer Level I
About the Occult

One of satan's favorite weapons agaiinst us is occult involvement. The occult (meaning "secret" or "hidden") is satan's world of the spirit. Occult involvement means that we seek to gain knowledge or personal power from a spiritual source other than God. The special danger of occult involvement is that it appeals to our spiritual hunger, which is our innate desire to find the Lord, and diverts us from Him into the occult underworld--a dead end. It is also a form of idolatry.

When we open ourselves up to the occult involvement, we violate the first commandment, "You shall have no other God but Me." (Exodus 20:3) and Jesus' commandment, "You shall love the Lrod your God with all your heart and with all your soul and with all your mind and with all you strength." (Deut. 6:4-9; Matt. 22:37; Mark 12:30; Luke 10:27). Remember also that the wrong things that we do in innocence and ignorance hurt as much as the thing we do deliberately.

Satan has set occult traps throughout our world into which he hopes that we will fall. God's way of healing us through confessions, renouncement, and forgiveness works not only for our sins, but also for our errors and ignorance.

As you read through the following list, ask the Holy Spirit to recall to your mind every involvement you have had. Keep in mind that many of these activities are clearly of the occult, but the occult nature of some of them may not be as clear. Please mark any and all possible activities, even if there is a question in your mind as to their occult nature, so that you are confident you renounce all possible occult or demonic influence in your life.

Have you ever- just for fun, out of curiority, or in earnest, done any of the following?
Soothsayers/Fortune Tellers: (Deut 18:9-16; Daniel 2:26-28; Isaiah 2:6, 47:10-15; Micah 5:12; Acts 16:15)
Have you ever had your fortune told by tea leaves, palm reading, crystal ball, fortune teller, etc?
Have you ever read or followed horoscopes, or had a chart made for yourself to predict your future? Have you ever read any other types of birth signs?
Have you ever been hypnotized, practiced self-hypnosis, yoga, or transcendental meditation? Have you ever been involved in charming or enchanting (attempts to use spirit power?)
Have you ever participated in the practice of Rheiki, Reflexology, the use of Crystals?
Additional notes on your answers in this section.
Necromancy, Spiritualism (1 Sam. 28:7-11; II Kings 21:6; Isaiah 8:19-22; Leviticus 19:31, 20:6)
Have you ever attended a seance or spiritualist meeting?
Do you beleive in reincarnation? Have you ever had a reincarnation reading?
Have you ever played with a Ouija board, crystal ball, Dungeons & Dragons, Magic 8 Ball, or other occult games?
Have you ever had a Tarot card reading, angel card reading or practiced cartomancy (using playing cards for fortune telling or other magical purposes?)
Have you ever played games of an occult nature, using ESP, telepathy, hypnotism, etc.?
Have you ever consulted a medium, spiritualist, or numerologist? Have you ever acted as a medium? Have you ever practiced channeling?
Have you ever seen and/or communicated with apparitions that are not of God?
Have you ever sought healing through magic spells or charms, or through a Christian Scientist or spiritualist? Have you ever sought psychic healing or had psychic surgery?
Have you ever been involved in acupuncture? (This practice is an example of a practice that is not always occult, but it can be of the occult and should be renounced in case any occult or demonic influence was present.)
Have you ever practiced table lifting, levitation of objects, pendulum swinging, lifting of bodies, automatic writing, astral travel or soul-travel?
Have you ever used a charm or amulet of any kind for protection or "good luck?" Are you superstitious?
Have you ever participated in chain letters?
Have you ever practiced water witching or dowsing to find out information such as where to dig a well?
To your knowledge, have you ever practiced any other kinds of black arts?
Have you ever participated in the practice of New Age Course of Miracles/Relaxation therapy? Alternative medicine?
Additional notes on your answers in this section.
Occult Books, "Contact" Objects, and Other Media (Ex. 19:25-10:6; deut. 5:8-10, 7:46, 24-26; I Kings 14:7-11; II Kings 23:1-25; Ps. 97:7; Isa. 42:17; Acts 19-:19-20; II Cor. 10:3-5)
Have you read or possessed books on astrology, interpretation of dreams (non-Christian), augury or interpretation of omens, cults, or other religious groups which deviate from scriptural Christian doctrine such as Christian Science, Unity, Scientology, or Science of the Mind?
Have you read or possessed books on witchcraft, fortune telling, magic, ESP, psychic phenomena, or possession?
Do you have anything in your home that was given to you by someone in the occult? Do you have anything in your home of an occult nature?
Have you followed the writings of Edgar Cayce, Jean Dixon, Shirley MacLaine, L. Ron Hubbard (Church of Scientology) or any other New Age author?
Do you find yourself intereted in demonic types of movies, such as The exorcist, Rosemary's Baby, or The Omen? Are you drawn to horror shows or scary movies such as Friday the 13th? Are you fascinated with evil or the occult?
Have you accepted the humanist theory that man is self-sufficient and does not need God?
Have you ever listened to hard or acid rock music with a satanic influence or music with a New Age influence?
Have you ever visited or worshiped in a shrine or temple of a non-Judeo/Christian religion? Do you possess any books, articles, or statues from any of these religions?
Additional notes on your answers in this section.
Sorcery or Magic (II Kings 17:17, 21:6; Isa. 47:9; Malachi 3:5; Acts 8:11, 13:4-12; Revelation 18:23; 21:8)
Have you ever practiced sorcery or magic?
Have you ever practiced mind control over any person or animal, cast a magic spell, or sought a psychic experience? Have you ever contacted a psychic in person or through a psychic hotline?
Additional notes on your answers in this section.
Sins of the Flesh, Sins of the Eyes (Matt. 5:28; Rom. 6:12-14; 7:7-25; 8:13-14; I Cor. 6:13, 18-20; 9:26-27; Gal. 5:16-21; I Thess. 4:3-8; James 1:14-15; I Pet. 2:11; I John 2:16)
Have you ever used LSD, marijuana, cocaine, crack cocaine, or any mind-expanding or mind-altering drugs? Have you ever abused prescription drugs? Have you ever viewed abstract art while under hallucinogenic stimulus?
Have you ever had a problem with alcohol?
Have you ever exposed yourself to pornography in magazines, Playboy pictures, ther internet, TV or stage shows, books, topless bars, or X-rated movies?
Have you ever had a problem with habitual masturbation?
Have you seen shows about sexual deviation, homosexuality, or lesbianism?
Have you been involved in sexual deviation, homosexuality, or lesbianism?
Have you been involved in group sex or bestiality?
Have you ever had sexual relations with a person who was not your legal spouse?
If possible please recall them by name (first name or initial is sufficient)
Have you had an abortion or have you fathered a child who was aborted?
Have you been involved in abortion in any way (viewed/witnessed one, assisted in one, performed one, encouraged a friend to have one, had a botched one, etc)
Additional notes on your answers in this section.
Devil Worship (II Chronicles 11:15; Ps. 106:37; I Cor. 10:20-22; Rev. 9:20-21, 13:4)
Have you ever made a pact with satan or been involved in or witnessed satan worship or black magic?
Have you ever worn, owned, or had in your home the symbol of the ankh (a cross with a ring top that is used in satanic rites)?
Have you ever celebrated a black mass? Have you ever witnessed a black mass?
Have you ever made a blood subscription or pact?
Additional notes on your answers in this section.
Witchcraft (Gal 5:19-20; I Sam. 15:23, 28:7; II Kings 9:22, 23:24; I Chron. 10:13; Isa. 8:19, 19:3, 29:4; Micah 5:12)
Have you ever attended witchcraft or voodoo activities?
Have you ever been involved in Freemasonry, Eastern Star, De Molay, or Rainbox Girls, or other secret societies or lodges?
Have you ever wished someone else were dead? Wished you were dead?
Have you ever planned or attempted to take your own life?
Have you ever planned or attempted to take someone else's life?
Additional notes on your answers in this section.
Generational Influence (Ex. 34:6-7; Numbers 14:17-19; Deut. 5:8-10; Joshua 22:16-29; Ps. 33:11; Jeremiah 11:10-13; Acts 2:38-39)
Have other family members had problems with alcohol or drugs?
Do you know of any relatives or ancestors who have been into witchcraft, pagan religions, fortunetelling or strong superstitions, or used magic spells or potions?
Has anyone in your family been involved in Freemasonry, Eastern Star, De Molay, or Rainbow Girls or other secret societies or lodges?
Additional notes on your answers in this section.
Notice: We are obligated to report to relevant State agencies/law enforcement agencies any knowledge that we obtain of imminent or ongoing abuse, danger, or harm to others or yourself.
Part 6 of 7

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Release

Freedom Prayer makes no claims of effectiveness, nor do we guarantee results of this prayer session. However, we do believe that God answers prayer and that He heals diseases. By signing below, you are agreeing to hold Wellspring Church, Freedom Prayer, their staff and volunteers harmless for any liability connected to this voluntary prayer session. We recommend that if you are currently taking medications or are operating under the advice of a professional service, that you allow that therapist or doctor, etc. to confirm results of prayer before you alter any prescribed course of action. This form and all data recorded on it are the sole property of Freedom Prayer of Wellspring Church. All content will be held in confidence for the sole purpose of ministry to the above except as indicated in the testimony release below
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The Occult-

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