Deliverance

DELIVERANCE MINISTRY

Confidential Questionnaire

The purpose of this form is to help determine possible entry ways 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.

Your Details

* Indicates required field

First Name *

Last Name *

Address *

Phone Number *

Email address *

Ancestry

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.

Are you aware of ancestor involvement in any of these? If yes, please explain. *

Pre-Birth years and Birth

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

Was there any trauma during pregnancy by your mum or dad, divorce, words of "We shouldn't be having this child", etc.? If Yes, explain: *

Early Childhood

Early childhood fears, injuries, nightmares, see things in your room, felt evil presence? If Yes, explain: *

Any sexual abuse, or sexual embarrassment through childhood? If Yes, explain: *

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? If Yes, explain: *

Any physical abuse from parents or others? If Yes, explain: *

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, Pokémon cards, etc.? If Yes, explain: *

Please list accidents or injuries that come to your mind as being frightening to you at the time: *

Please list surgeries and approximate age: *

Movies or TV programs that were particularly frightening to you, or specific scenes that seem to stick in your memory: *

Have you participated in pre-marital sex? *

Drinking and/or drug use? *

Do you experience unusual fears? If Yes, explain: *

What do you think may be the areas of demonic influence in your life? *

Do you have problems in home? If Yes, explain: *

Are your parent's divorced? If Yes, how old were you? *

Unusual feelings such as: Never really felt loved, couldn't please my father/mother, feelings of worthlessness, etc.? If Yes, explain: *

Have you been exposed to pornography? If Yes, how old were you? *

General Life Questions

Please answer the following questions as they apply to your life

Do you have Homosexual tendencies? *

Participated in college fraternities or sororities? *

Feelings of guilt and shame? *

Hopelessness? *

Fatigue without medical reason? *

Abortion(s)? *

Difficulty in forgiving? *

Is there bitterness, anger, or unforgiveness? *

If so, can you forgive? *

Do you hate yourself? *

Have you suffered from self harm? *

Do you have feelings of gloom? *

Do you feel rejected? *

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 artifacts, wiccan, etc.? If Yes, can you give examples? *

Ever "felt" a presence in the room? If Yes, has it been recently? If either question was Yes, please explain: *

Do you have nightmares? *

When attending Church or other ministries do you have "foul" thoughts, jealousies or other mental harassment? *

Do you have difficulty retaining or reading God's Word? *

Do you have or get migraine headaches? *

Do you have any addictions? *

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

Do you have a fear of death? *

Do you ever have suicidal thoughts? *

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

Do you ever feel incredible loneliness? *

Are you plagued with doubt and unbelief? *

Do you feel inferior? *

Do you have thoughts of inadequacy? *

Do you have obsessive thoughts? *

Do you ever have blasphemous thoughts? *

Compulsive thoughts? *

Lustful thoughts? *

Do you ever daydream? *

Are you a perfectionist? *

Are things seemingly always out of order? *

Do you feel the need to be in control? *

Are you rebellious? *

Insecurity? (On a scale of 1-10 with 10 being worst)? *

Other symptoms of demonic attack

Here are a few symptoms of demonic attack, please write in the box below any symptom(s) 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 behaviour 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 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 which 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 your 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.

Which of the above symptoms applied to you? (Write down the numbers here) *

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!

There is something you can do to help bring about your freedom. It is recommended 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 occultic activities they must be renounced.
Typical prayer:  "Father, I denounce 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. Below is 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 cancelling 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 and choose to be free in Jesus Christ' Name. Amen"

Informed consent for personal ministry

I have been informed that the ministry of deliverance is a personal ministry based in religious belief and is not recognized by the secular field of psychology as a method for the resolution of psychological problems. I further understand that the personal ministry session/s will be conducted by ordinary Christians, and that they do not necessarily hold professional qualifications in counselling or psychology.

I will not hold any of the participants responsible for my memories or behaviours. I give my consent for personal ministry and deliverance, and I acknowledge and declare that I am in no way being forced, pressured, or coerced to submit to this procedure from any person or entity.

I also have the right to terminate the session at any time without penalty or consequences of any sort. There is no payment required of any sort, whether financial or otherwise. I understand the personal ministry is offered for free, and with no conditions attached.

I understand that there is no guarantee or commitment of continued or ongoing ministry, with pastors or team members, or associated team members. Abundant Life Centre team members reserves the right to discontinue a personal ministry session at any time, for any reason as they feel led.

I do understand that if I give any indication that I am currently suicidal or if there is new information about a current molestation of a minor that the personal ministry team may need to report this to legal authorities.

I am entering my name below as a legal acknowledgment that I have been informed of my rights and have had the opportunity to obtain whatever information or professional advice I deemed necessary or appropriate prior to undergoing personal ministry deliverance. I hereby do give my full consent, and of my own free will to go through with the personal ministry deliverance session/s as may be provided by Abundant LIfe Centre Busselton. I agree that I will not hold Abundant LIfe Centre Busselton or any of its members responsible or liable in any way and waive all rights to pursue any legal action for any adverse or potential negative consequences, whether perceived or otherwise, as a result of the personal ministry provided to me.

Please enter your full name as consent provided *

Date *

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