Oppression Healing In-­take Form

Form Instructions:

Please fill of the Pre-­‐Deliverance History form to prepare the deliverance team for their session with you. Write “N/A” (Not Applicable) in any area that does not apply to you. Please use additional paper if required and record the Question Number with your answer. Please sign the Liability Release at the bottom of the form. All information that you provide is strictly confidential and will be viewed only by the individual(s) involved in personal ministry with you.

Today’s Date:

Your Name:

Spouse’s Name:

Your Address:

Phone: Email:

Prior Marriages: Yes No If so, how many?

Names of Children:

Best Time To Meet: Week Days Weeks Nights Week Ends

The purpose of this form is to help determine possible entryways 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.

Please give any information that the Holy Spirit brings to your mind. 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 etc.

1. Are you aware of ancestor involvement in any of these? Yes No If Yes, explain:

Note: It is not necessary to go into great detail with any of your responses. Ask the Holy Spirit to show you any area of concern.

1. From birth and your early childhood: Are you aware of any trauma you might have experienced during your mother’s pregnancy? Accidents, divorce, spoken words such as “We shouldn’t be having this child”, etc.?
2. Do you recall any early childhood fears, injuries, nightmares? Do you remember seeing things in your room or feeling an evil presence? Do you recall any encounters of a supernatural kind?
3. Any sexual abuse, or sexual embarrassment through childhood?
4. Do you recall any 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?
5. Any physical abuse from parents or others?
6. 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.?
7. Please list accidents or injuries that come to your mind as being frightening to you at the time:
8. Please list surgeries and approximate age:
9. Movies or TV programs that were particularly frightening to you, or specific scenes that seem to stick in your memory:
10. Have you participated in pre-­‐marital sex? Yes No
11. Periods of, or habitual immorality? (including pornography, sexual fantasy, promiscuity, etc.)
12. Drinking and/or drug use?
13. Do you experience unusual fears?
14. What do you think may be the areas of demonic influence in your life?:
15. Are (or were) there any significant problems in the home?
16. Are your parent’s divorced? Yes No If Yes, how old were you?
17. Unusual feelings such as: Never really felt loved, couldn’t please my father/mother, feelings of worthlessness, etc.?
18. Have you been exposed to pornography? Yes No If Yes, how old were you?

Please answer the following questions as they apply to your life:

(Circle Yes or No)

1. Homosexual tendencies?

Yes No

1. Participated in college fraternities or sororities?

Yes No

1. Feelings of guilt and shame?

Yes No

1. Hopelessness?

Yes No

1. Fatigue without medical reason?

Yes No

1. Have you had an Abortion?

Yes No

1. Difficulty in forgiving?

Yes No

1. Is there bitterness, anger, or unforgiveness?

Yes No

1. If so, can you forgive?

Yes No

1. Do you experience feelings of self-­‐hate?

Yes No

1. Have you suffered from self harm?

Yes No

1. Do you have feelings of gloom?

Yes No

1. Do you feel rejected?

Yes No

1. 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/African artifacts, Items connected with other religions or rituals, Wiccan or other occult items, etc.?

Yes No

If Yes, Please identify or explain:

34a.) Have you ever “felt” a presence in the room?: Yes No

34b.) If Yes, has it been recently?

Yes No

If either question was Yes, please explain:

35a.) Do you have nightmares?

Yes No

35b.) If Yes, do you hear voices?

Yes No

If either question was Yes, please give an example:

1. Have you been diagnosed by a doctor as having: (list any diagnosis, diabetes, asthma hypertension, etc.)?

Yes No

If Yes, list the diagnosis here:

1. Do you have inexplicable pain…no medical explanation for it?

Yes No

If Yes, please explain:

1. Do you have difficulty in trusting others?

Yes No

If Yes, do you know why? Please explain:

1. Has there been a death of someone close to you?

Yes No

If so, whom?

1. Do you feel like you have any eating disorders?

Yes No

If Yes, do you know when they begin? Please give approximate height and weight:

Height: Weight:

1. Do you suffer from sleep disorders?

Yes No

1. Any other medically defined disorder?

Yes No

If Yes, please explain:

1. Is there a history of tuberculosis, diabetes, ulcers, cancer, heart disease, glandular problems, asthma, other in your family?

Yes No

If Yes, please explain:

1. Did you have imaginary friends as a child?

Yes No

If Yes, what were their names:

1. When attending Church or other ministries do you have “foul” thoughts, jealousies or other mental harassment?

Yes No

1. Do you have difficulty retaining God’s Word?

Yes No

1. Difficulty in reading it?

Yes No

1. Do you have migraine headaches?

Yes No

1. Do you have any addictions?

Yes No

1. Were you ever diagnosed with a learning disability i.e. (A.D.D.), etc?

Yes No

1. Do you have a fear of death?

Yes No

1. Have you ever had suicidal thoughts?

Yes No

1. Has there been a period of time in your life when you were angry with God?

Yes No

1. Do you have a fear of losing your mind?

Yes No

1. Do you suffer from anxiety or panic attacks?

Yes No

If Yes, when and how did they begin?

1. Do you feel incredible loneliness?

Yes No

1. Are you plagued with doubt and unbelief?

Yes No

1. Do you feel inferior? Yes No
2. Do you have thoughts of inadequacy?

Yes No

1. Do you have obsessive thoughts?

Yes No

1. Blasphemous thoughts?

Yes No

1. Compulsive thoughts?

Yes No

1. Lustful thoughts?

Yes No

1. Do you daydream? Yes No
2. Are you a perfectionist?

Yes No

1. Are things seemingly always out of order?

Yes No

1. Do you feel the need to be in control?

Yes No

1. Are you rebellious? Yes No
2. Feelings of Insecurity? (On a scale of 1-­‐10 with 10 being worst)

1 2 3 4 5 6 7 8 9 10

Please briefly explain your response:

1. Here are a few symptoms of demonic attack, please check any symptom that applies to you:
   • A compulsive desire to blaspheme God.
   • A revulsion against the Bible, including a desire to tear it up or destroy it.
   • Compulsive thoughts of suicide or murder.
   • Deep feelings of bitterness and hatred toward others without reason: Jews, other races, the church, strong Christian leaders.
   • Any compulsive temptations, which seek to force you to thoughts or behavior which you truly do not want to do or think.
   • Compulsive desires to tear other people down, even if it means lying to do so. Vicious cutting down of others by the tongue.
   • Terrifying feelings of guilt even after honest confession is made to the Lord.
   • Certain physical symptoms which may appear suddenly or leave quickly and there are no physical or physiological reason.
   • Choking sensations.
   • Pains that seem to move around and for which there is no medical cause.
   • Feelings of tightness about the head or eyes.
   • Dizziness, blackouts, or fainting seizures.
   • Deep depression and despondency.
   • Sudden surges of violent rage, uncontrollable anger, or seething feelings of hostility.
   • Terrifying doubt of one’s salvation even though they once knew the joy of salvation.
   • Seizures of panic or other fear that is terrifying.
   • Dreams or nightmares that are of a horrific nature and often recurring. Clairvoyant dreams that may even come true are most often demonic.
   • Abnormal or perverted sexual desires.
   • Questions and challenges to God’s Word.
   • Sleep or eating disorders without physical cause.
   • Most compulsions and obsessions.
   • Rebellion and hatred for authority.
   • Bizarre terrifying thoughts that seem to come from nowhere and you cannot control them.
   • Fascination with the occult.
   • Involvement in criminal activity.
   • Extremely low self-­‐image (unworthy, a failure, no good -­‐ a constant undermining of the self-­‐identity).
   • Constant confusion in thinking (sometimes great difficulty in remembering things).
   • Inability to believe (even when the person wants to).
   • Mocking and blasphemous thoughts against preaching/teaching of the Word of God.
   • Perceptual distortions -­‐ perceiving anger, hostility, in others when it doesn’t really exist -­‐ seeing only judgment in the scriptures.
   • Horrible nightmares causing fear (often having demonic images).
   • Violent thoughts (suicidal, homicidal, encouraging self-­‐abuse, etc.).
   • Hatred and bitterness toward others for no justifiable reason.
   • Tremendous hostility or fear when encountering someone involved in deliverance work.
   • Feelings of being watched or sensing an evil presence.
   • Deep depression and despondency (frequently and at significant times).
   • Irrational fears -­‐ panic attacks -­‐ phobias.
   • Irrational anger -­‐ rage.
   • Irrational guilt -­‐ self-­‐condemnation to the extreme.
   • Desire to do what is right (inability to carry it out).
   • Sudden personality and attitude changes (severe contrasts -­‐ appears schizophrenic) Bi-­‐polar disorder.
   • A strong aversion toward scripture reading and prayer (especially one on one).
   • 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 others directly.
   • Lying, exaggerating, or stealing compulsively (often wondering why).
   • Drug abuse (especially when there is demonic hallucinations).
   • Eating obsessions -­‐ bulimia, anorexia nervosa.
   • Compulsive sexual sins (especially perversions).
   • Irrational laughter or crying.
   • Irrational violence -­‐ compulsion to hurt self and/or someone else.
   • Sudden speaking of a language not previously known (often an ethnic language of ancestors).
   • Reactions to the name and blood of Jesus Christ (verbally or through body language).
   • Extreme restlessness (especially in a spiritual environment).
   • Uncontrollable cutting and mocking tongue.
   • Vulgar language and actions.
   • 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).
   • Extreme sleepiness around spiritual things.
   • Demonstration of extraordinary abilities (either ESP or Telekinesis).
   • Voices are heard in the mind (they mock, intimidate, accuse, threaten or bargain).
   • Voice -­‐ refers to him/her in the third person.
   • Supernatural experiences -­‐ hauntings, movement or disappearance of objects, and other strange manifestations.
   • Seizures (too long and/or too regular).
   • Pain (without justifiable explanation -­‐ especially in head and/or stomach).
   • Blackouts.
   • Physical ailments can often be alleviated immediately by a command of spiritual authority (i.e. epileptic seizure, asthma attacks, various pains).
   • 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.

Note: A few 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!

Additional Comments:

Before Coming For Deliverance:

There is something you can do to help bring about your freedom. I recommend that you deal with these issues before coming for deliverance.

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 occult activities they must be renounced. Typical prayer:

“Father, I renounce 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 them and choose to be free in Jesus Christ’ Name. Amen”

I hereby acknowledge and affirm that all answers given by myself in response to the questions in this form are voluntarily submitted and that the information is true to the best of my knowledge. I hereby release, indemnify and forever hold harmless

and its agents, staff, employees and volunteers of any damages, real or perceptual, arising from personal ministry in connection with the information submitted herein.

Name: (Please print)

Name of Parent or Legal Guardian if person filling out the form is under age of 18:

Signature: (Parent or Legal Guardian must sign if under 18 years of age)

Date:

Please fill of the Pre-­‐Deliverance History form to prepare the deliverance team for their session with you. Write “N/A” (Not Applicable) in any area that does not apply to you. Please use additional paper if required and record the Question Number with your answer. Please sign the Liability Release at the bottom of the form. All information that you provide is strictly confidential and will be viewed only by the individual(s) involved in personal ministry with you.