Clone of Deliverance Course Questionnaire

Confidentiality Notice

All information provided in this intake form is treated as strictly confidential and will not be shared without your consent, except where legally required or where there is risk of harm.

PLEASE SELECT THE RELEVANT OPTION/S YOU NEED COUNSELLING/HELP/SUPPORT WITH

Satanic Ritual Abuse

Deliverance (Oppression/possession)

SRA and DID

Counselling

Addiction

Trauma Counselling

Healing

Please complete all fields

First Name

Last Name

EMAIL ADDRESS

example@example.com

PERSONAL DETAILS

Date of Birth

Gender

Marital Status

Number of previous marriages (if any)

CHILDREN

Number of Children

Names and ages

ADDRESSResidential Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

YOUR CONTACT NUMBERCell

ALTERNATIVE CONTACT NUMBERCell

RESPONSIBLE PERSON (If Different from client/minors)

Name & Surname

Relation to Client

Contact Details

CONSENT & BACKGROUNDDid you come willingly?

YES

UNSURE

CONSENT & BACKGROUNDIf under 18, do you have parental/guardian consent?

YES

UNSURE

CONSENT & BACKGROUNDPreferred Language

Preferred Language

If other, what Language do you prefer?

Referred by?

Do you wantPlease pick relevant boxes

Prayer

Counselling

Deliverance

EXPECTATIONSWhat is your expectation or desired outcome from counselling?

WHAT IS YOUR IMMEDIATE NEEDWhat is your immediate need(s)?

HAVE YOU EVER BEEN FOR COUNSELLING BEFORE

YESNO

PLEASE PROVIDE YOUR COUNSELLING HISTORY

HAVE YOU EVER BEEN FOR DELIVERANCE

YESNO

PLEASE GIVE A BREAKDOWN OF YOUR PREVIOUS DELIVERANCE EXPERIENCE

BRIEFLY STATE YOUR REASON FOR SEEKING HELPI am here because...

LIFE SATISFACTION & FUNCTIONINGPlease rate your level of fulfilment on the following: RELATIONSHIP WITH GOD

1 Very Poor

2 a little bit

3 so-so

4 Good

5 Very Good

N/A = Not Applicable

LIFE SATISFACTION & FUNCTIONINGPlease rate your level of fulfilment on the following: MARRIAGE / RELATIONSHIP

1 Very Poor

2 a little bit

3 so-so

4 Good

5 Very Good

N/A = Not Applicable

LIFE SATISFACTION & FUNCTIONINGPlease rate your level of fulfilment on the following: FAMILY

1 Very Poor

2 a little bit

3 so-so

4 Good

5 Very Good

N/A = Not Applicable

LIFE SATISFACTION & FUNCTIONINGPlease rate your level of fulfilment on the following: CHILDREN

1 Very Poor

2 a little bit

3 so-so

4 Good

5 Very Good

N/A = Not Applicable

LIFE SATISFACTION & FUNCTIONINGPlease rate your level of fulfilment on the following: WORK /SCHOOL

1 Very Poor

2 a little bit

3 so-so

4 Good

5 Very Good

N/A = Not Applicable

LIFE SATISFACTION & FUNCTIONINGPlease rate your level of fulfilment on the following: PHYSICAL HEALTH

1 Very Poor

2 a little bit

3 so-so

4 Good

5 Very Good

N/A = Not Applicable

LIFE SATISFACTION & FUNCTIONINGPlease rate your level of fulfilment on the following: MENTAL / EMOTIONAL HEALTH

1 Very Poor

2 a little bit

3 so-so

4 Good

5 Very Good

N/A = Not Applicable

LIFE SATISFACTION & FUNCTIONINGPlease rate your level of fulfilment on the following: SLEEP

1 Very Poor

2 a little bit

3 so-so

4 Good

5 Very Good

N/A = Not Applicable

LIFE SATISFACTION & FUNCTIONINGPlease rate your level of fulfilment on the following: HABITS / LIFESTYLE

1 Very Poor

2 a little bit

3 so-so

4 Good

5 Very Good

N/A = Not Applicable

LIFE SATISFACTION & FUNCTIONINGPlease rate your level of fulfilment on the following: CALLING / PURPOSE

1 Very Poor

2 a little bit

3 so-so

4 Good

5 Very Good

N/A = Not Applicable

WHAT BELIEF SYSTEM DO YOU CURRENTLY FOLLOW?Faith & Spiritual Background

WHERE DO YOU ATTEND (CHURCH / GROUP)?Faith & Spiritual Background

WHAT BELIEF SYSTEM WERE YOU RAISED IN?Faith & Spiritual Background

ARE YOU BORN AGAIN?Christian Faith

Yes

Unsure

Date of Salvation

HAVE YOU BEEN WATER BAPTISED?Christian Faith

Yes

Unsure

ARE YOU BAPTISED IN THE HOLY SPIRIT?Christian Faith

Yes

Unsure

PLEASE EXPLAIN WHAT JESUS CHRIST MEANS TO YOU?

WHAT DO YOU DAILY DO TO STRENGTHEN YOUR RELATIONSHIP WITH JESUS CHRIST?

WERE YOU WANTED AS A CHILD?Family & Developmental History

Yes

Unsure

ANY PREGNANCY OR BIRTH COMPLICATIONS KNOWN?

Yes

Unsure

IF YES OR UNSURE, ON ANY PREGNANCY OR BIRTH COMPLICATIONS KNOWN, PLEASE EXPLAIN

BIRTH ORDER (E.G OLDEST, YOUNGEST)Family & Developmental History

PARENTSParents / Caregivers

Married

Separated

Divorced

Deceased

Unknown

RELATIONSHIP WITH FATHER

Good

Fair

Difficult

Absent

RELATIONSHIP WITH MOTHER

Good

Fair

Difficult

Absent

WOULD YOU DESCRIBE YOUR CHILDHOOD AS SAFE?Childhood Environment

Yes

Unsure

ANY FORM OF ABUSE EXPERIENCED (VERBAL, PHYSICAL, EMOTIONAL, SEXUAL, SPIRITUAL)?

Yes

Prefer not to say

Unsure

HAVE YOU OR YOUR FAMILY BEEN INVOLVED IN ANY OF THE FOLLOWING PAST OR PRESENT?Occult / Spiritual Involvement

Witchcraft

New Age

Satanism

Paganism

Ancestral Worship

Divination

Freemasonry

Eastern Religions

Occult Healing Practices

Other

IF ANSWERED "OTHER" IN THE QUESTION IF YOU OR YOUR FAMILY BEEN INVOLVED IN ANY OF THE FOLLOWING PAST OR PRESENT, PLEASE EXPLAIN.

HAVE YOU PARTICIPATED IN PRACTICES SUCH AS:

Tarot

Astrology

Reiki

Meditation / Yoga

Spirit Guides

Astral Projection

Rituals

Other

IF ANSWERED "OTHER" IN THE QUESTION, HAVE YOU PARTICIPATED IN PRACTICES, PLEASE EXPLAIN.

DO YOU STILL POSSESS RELATED OBJECTS, SYMBOLS, BOOKS OR ITEMS?

Yes

Unsure

HAVE YOU MADE ANY VOWS, PACTS OR AGREEMENTS?Occult / Spiritual Involvement

Yes

Unsure

HAVE YOU EXPERIENCED SEXUAL ABUSE OR TRAUMA?Trauma, Sexual History & Boundaries

Yes

Unsure

Prefer not to say

ANY HISTORY OF PORNOGRAPHY, SEXUAL ADDICTION OR EXPLOITATION?

Yes

Unsure

ANY ABORTIONS, MISCARRIAGES OR SEXUAL TRAUMA REQUIRING MINISTRY?

Yes

Unsure

PLEASE INDICATE CURRENT OR PAST STRUGGLES:Addictions & Dependencies

Alcohol

Drugs

Medication

Pornography

Gambling

Food

Technology

Other

Work

IF ANSWERED "OTHER" IN THE QUESTION ABOUT CURRENT OR PAST STRUGGLES, PLEASE EXPLAIN

FAMILY HISTORY OF ADDICTION?

Yes

Unsure

ANY DIAGNOSED MENTAL HEALTH CONDITIONS?Medical & Mental Health

Yes

Unsure

ARE YOU CURRENTLY ON MEDICATION?

Yes

PLEASE LIST ALL PSYCHIATRIC MEDICATIONS AND DOSAGES

PLEASE GIVE FULL MENTAL HISTORY.

ANY SERIOUS MEDICAL CONDITIONS?

Yes

IF ANSWERED "YES" IN THE QUESTION: "ANY SERIOUS MEDICAL CONDITIONS", PLEASE EXPLAIN.

PLEASE MENTION ANYTHING ELSE YOU THINK MIGHT BE IMPORTANT THAT WE HAVE NOT ASKED ABOUT.

I SEE MYSELF AS:Personal Reflection

I STRUGGLE MOST WITH:

I AM AFRAID OF:

MY RELATIONSHIP WITH GOD CURRENTLY FEELS LIKE:

AGREEMENT & CONSENTI confirm that the information provided is truthful to the best of my knowledge. I understand that Deliverance HUB operates from a Christian, Bible-based worldview, and that ministry does not replace professional medical or psychiatric care where required. I consent to receive ministry support, prayer and guidance.

YESNO

Client Name & Surname

First Name

Last Name

Parent / Guardian Name & Surname if applicable

First Name

Last Name

DATE SIGNED BY THE APPLICANT

Date

Clone of Deliverance Course Questionnaire