Ministry Form | Deliverance Ministries

Name*

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Phone*

Mobile Phone

Birth Date

Church Affiliation

Marital Status

I was Referred By

What Is The Primary Help You Want?

Tell Us About Your Relationship With Your Biological Father

Tell Us About Your Relationship With Step-Fathers, Step-Mothers & Siblings

Were You Adopted?

YES
NO

At What Age Were You Adopted?

List Any Traumas That Negatively Impacted Your Life

Have You Been Abused Sexually?

YES
NO

How Has It Impacted Your Life?

Have You or Your Ancestors Ever Been Involved in Witchcraft (white or black)?

YES
NO

Who, What Relationship, and How Didi It Affect You?

Have You or Anyone in Your Family Been Members of Freemasonry, Eastern Star or Other Secret Societies?

YES
NO

If Yes, Which Organizations?

How Many Times Have You Been Maried? What are the Names of Your Ex-Spouses?

How Many Sexual Partners Have You Had? Please Name the Significant Relationships.

Medical Diagnosis

Psychological Diagnosis

List All Medications Prescribed For You

Do You Take This (These)?

YES
NO

Tell Us Your Story

Do You Read Your Bible Out Loud?

YES
NO

Do You Attend Church Regularly?

YES
NO

Do You Spend Time Fellowshipping With Jesus, Talking With Him About Your Life, Your Concerns, and Your Desires?

YES
NO

Do You Fellowship With Other Believers?

YES
NO

If So, How Do You Fellowship With Other Believers?

Describe Your Support System:

How Do You Spend Your Leisure Time?

What Do You Do When You Feel Fear, Stress, or Anxiety?

What Crisis Have You Had to Deal With?

What Addictions Do You Want to Overcome?

Thank you for taking the time to help us help you. We will use the answers to this survey to set a course in ministry. Your candor and honesty is most important for us to be able to help you. Our desire is to glorify the Lord Jesus Christ by doing the SUPERNATURAL works of Jesus.