Phone number
Phone type Mobile Home Work Other
Gender
Select… Male Female
Marital status
Select… Single Married Widowed
Have you been previously married? *
Involvement (however innocently it may have been) with Ouija boards, levitation games, Bloody Mary games, seances, fortune tellers, tarot cards, astrology, horoscopes, fascination about books of magic, psychics?
Names and ages of children *
Have you trusted in Jesus for the forgiveness of your sins? *
Are you seeking prayer for healing or deliverance? *
Are you aware of any ancestors who have involvement in any of the organizations listed above, or other similar organizations? (If no, just put "NA" *
From birth to 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 have this child") *
Do you recall any childhood fears, injuries, nightmares? Do. you remember seeing things in your room, sensing an evil presence? Do you recall any supernatural encounters of any kind? *
Any sexual abuse or sexual embarrassment during your childhood? *
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. Or have you had any embarrassing/humiliating experiences? *
Any physical abuse from parents or others? *
Please list accidents or injuries that come to mind as being frightening to you at the time: *
Please list surgeries and approximate age: *
Movies or shows that were particularly frightening to you, or specific scenes that seem to stick with you: *
Have you participated in premarital sex? *
Periods of, or habitual immorality? (including pornography, sexual fantasy, promiscuity...etc.)? *
Drinking and/or drug use? *
Do you experience unusual fears? *
What do you think may be the areas of demonic influence in your life? Why? *
Are (or were) there any significant problems in your home? *
Are your parents divorced? *
Any unusual feelings, such as: Never really felt loved, couldn't please my father/mother, feelings of unworthiness...etc.? *
Have you been exposed to pornography? *
Participated in college fraternities or sororities? *
Feelings of guilt and shame? *
Fatigue without medical reason? *
Have you had an abortion? *
Difficulty in forgiving? *
Is there bitterness, anger, unforgiveness? *
Is there bitterness, anger, unforgiveness? *
If there is bitterness, anger, unforgiveness, are you able to forgive? *
Do you experience feelings of self-hate? *
Have you experienced self-harm? *
Do you have feelings of gloom? *
Do you have any objects in your home or possession that relate to ungodliness or cults? *
This may 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? (This may include Native American dream catchers).
Have you ever "felt" a presence in the room? *
Do you have nightmares? *
Have you received any medical or psychological diagnosis from a doctor or medical professional? *
Do you have inexplicable pain...no medical explanation for it? *
Do you have difficulty trusting others? *
Has someone close to you died? *
Do you feel like you have any eating disorders? *
Do you suffer from sleep disorders? *
Is there any other medically defined disorder that you are aware of? *
Is there a history of tuberculosis, diabetes, cancer, ulcers, heart disease, glandular problems, asthma, or other things in your family? *
Did you have imaginary friends as a child? *
When attending church services, or other ministries, do you have foul thoughts, jealousies, or other mental harassment? *
Do you have difficulty retaining God's Word? *
Do you have difficulty reading God's Word? *
Do you have migraine headaches? *
Do you have any addictions? *
Were you ever diagnosed with a learning disability? (i.e. A.D.D., A.D.H.D...etc.) *
Do you have a fear of death? *
Have you ever had suicidal thoughts? *
Has there been a period in your life when you were angry with God? *
Do you have a fear of losing your mind? *
Do you suffer from anxiety or panic attacks? *
Do you feel incredible loneliness? *
Are you plagued with doubt and unbelief? *
Do you have thoughts of inadequacy? *
Do you have obsessive thoughts? *
Do you have blasphemous thoughts? *
Do you have compulsive thoughts? *
Do you have lustful thoughts? *
Are you a perfectionist? *
Are things seemingly out of order? *
Do you feel the need to be in control? *
Do you have feelings of insecurity? *
Does it seem like you are "accident prone?" *
The following is a list of symptoms that may indicate demonic attack (note just because you may have some of these does not mean it is necessarily demonic, these are just common). Check all that apply. *
A compulsive desire to blaspheme God
A revulsion against the Bible, included a desire to tear it up or destroy it
Compulsive thoughts of suicide or murder
Deep feelings of bitterness or hatred toward others with no apparent reason (individuals in your life, Jews, the Church, other races, Christian leaders...etc.)
Compulsive desires to tear other people down, even lying to do so
Certain physical symptoms that suddenly appear and disappear and have no apparent physiological explanation
Choking sensations
Pains that seem to move around and for which there is no apparent medical explanation
Feeling of tightness about the head or eyes
Dizziness, fainting seizures, or black outs
Terrifying doubt of your salvation even though you once knew the joy of salvation
Seizures of panic or other fears that are terrifying
Dreams or nightmares that are of a horrific nature and may be reoccurring
Compulsions or obsessions
Rebellion and hatred for authority
Bizarre terrifying thoughts that seem to come from nowhere and you have no way to control them
Fascination with the occult
Involvement in criminal activity
Constant confusion in thinking
Horrible nightmares causing fear (especially with demonic images)
Feelings of being watched or sensing and evil presence
Severe personality and attitude changes (severe contrasts - appears schizophrenic, bi-polar)
A dark countenance (steely or hollow look in the 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)
Irrational laughter or crying
Sudden speaking of a language not previously known (often an ethnic language of ancestors)
Extreme restlessness (especially in a religious environment)
Vulgar language or actions
Loss of time (from minutes to hours - ending up in a place, but not knowing how you got there - regularly doing things of which there is no memory)
Extreme sleepiness around spiritual things
Demonstration of extraordinary abilities (ESP, or Telekinesis, extreme strength)
Supernatural experiences (hauntings, objects move or disappear with no explanation, other strange manifestations)
Seizures (too long or too regular)
Pain (without justifiable explanation, especially in the head or stomach)
Blackouts
Any additional comments or things you would add that have not come up in this questionnaire... *
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 The Gathering Community Church and its agents, staff, employees and volunteers of any damages, real or perceptual, arising from personal ministry in connection with the information submitted herein.
Submit
