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Inner Healing & Deliverance Questionnaire

Confidentiality Notice: All information submitted through this questionnaire is kept private and confidential and is used solely for ministry purposes.

Personal Information

First Name

Last Name

Phone

Marital Status

State

Country

How did you hear about Deliverance360?

Readiness Questions

Are you currently under medical care?

Are you currently taking medication?

Have you received deliverance ministry before?

Have you knowingly participated in occult activity?

Do you believe Jesus Christ is the Son of God and your Lord and Savior?

Have you fully forgiven those who have hurt you?

Alcohol

Smoking

Anorexia / Bulimia

Food

Caffeine

Gambling

Sex

Daydreaming

Distraction

ADD

MPD / Multiple Personality

Confusion

Arrogance

Idleness

Obstinance

Defensiveness

Controlling / Overbearing

Boastfulness / Bragging

Occult Movies

Violent Movies

Pokemon

Furbee

Dungeons and Dragons

Other Role Playing

Yoga

Transcendental Meditation

Clairvoyance / ESP

Mind Control

Voodoo

Hypnosis

Far East Sports / Judo

Fear / Doubt / Anxiety

Nightmares

Suspicion / Untrust

Fear of Man

Introversion

Stress

Heaviness / Blackness

Excessive Mourning

Sorrow

Self-Pity

Insomnia

Fraternities / Sororities

Knights of Columbus

Masonic Orders / Masons

Demolay

KKK

Rainbow Girls

Eastern Star

Prayer Request

Please describe why you are seeking deliverance or inner healing.

Anything else we should know?

Ministry Covenant & Consent

I understand that Deliverance360 is a Christian ministry and not a licensed medical, psychiatric, psychological, or legal service.

I understand that Inner Healing and Deliverance Ministry is prayer ministry based upon biblical principles and the power of Jesus Christ.

I understand that participation in this ministry is voluntary and that freedom often requires repentance, forgiveness, renunciation of sin, and submission to Jesus Christ.

I have read and agree to the Ministry Covenant and Consent Statement.

I voluntarily participate in Deliverance360 ministry sessions and release Deliverance360 and its ministers from liability associated with my participation.

Inner Healing & Deliverance Questionnaire

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Inner Healing & Deliverance Questionnaire

Drugs

Addictions

Sexual History

Mental Focus

Pride

Character Issues

Entertainment

Witchcraft

New Age

Other Areas

Depression / Fear

Grief

Other Religions

Secret Societies