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:   ______________________________________________________________________  
      ______________________________________________________________________  
      ______________________________________________________________________  
      ______________________________________________________________________  
 
Date  of  Birth:     ____________________________________________  
 
Were  you  the  first  born?     Yes          No      
Are  you  a  Born-­‐Again  Christian?   Yes          No      
Where  and  at  approximately  what  age?     ____________________________________________  
   
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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.    
2.)    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.?  
 
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3.)    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?    
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4.)    Any  sexual  abuse,  or  sexual  embarrassment  through  childhood?    
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5.)    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?        
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6.)    Any  physical  abuse  from  parents  or  others?    
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7.)    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.?    
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8.)    Please  list  accidents  or  injuries  that  come  to  your  mind  as  being  frightening  to  
you  at  the  time:    
     
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9.)    Please  list  surgeries  and  approximate  age:    
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10.)    Movies  or  TV  programs  that  were  particularly  frightening  to  you,  or  specific  
scenes  that  seem  to  stick  in  your  memory:      
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11.)    Have  you  participated  in  pre-­‐marital  sex?       Yes          No      
 
12.)    Periods  of,  or  habitual  immorality?    (including  pornography,  sexual  fantasy,  
promiscuity,  etc.)  
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13.)    Drinking  and/or  drug  use?    
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14.)    Do  you  experience  unusual  fears?      
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15.)    What  do  you  think  may  be  the  areas  of  demonic  influence  in  your  life?:    
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16.)    Are  (or  were)  there  any  significant  problems  in  the  home?        
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17.)    Are  your  parent's  divorced?       Yes          No      
 
If  Yes,  how  old  were  you?   ___________    
 
18.)    Unusual  feelings  such  as:  Never  really  felt  loved,  couldn't  please  my  
father/mother,  feelings  of  worthlessness,  etc.?        
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19.)    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)  
20.)    Homosexual  tendencies?    
    Yes           No    
21.)    Participated  in  college  fraternities  or  sororities?    
    Yes           No    
22.)    Feelings  of  guilt  and  shame?    
    Yes           No    
  5  
  
23.)    Hopelessness?    
    Yes           No    
24.)    Fatigue  without  medical  reason?    
    Yes           No    
25.)    Have  you  had  an  Abortion?    
   Yes           No    
26.)    Difficulty  in  forgiving?    
    Yes          No    
27.)    Is  there  bitterness,  anger,  or  unforgiveness?  
    Yes           No    
28.)    If  so,  can  you  forgive?    
    Yes          No    
29.)    Do  you  experience  feelings  of  self-­‐hate?    
    Yes           No    
30.)    Have  you  suffered  from  self  harm?    
    Yes           No    
31.)    Do  you  have  feelings  of  gloom?    
    Yes           No    
32.)    Do  you  feel  rejected?    
    Yes           No    
 
33.)    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:  
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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:    
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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:    
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36.)    Have  you  been  diagnosed  by  a  doctor  as  having:  (list  any  diagnosis,  diabetes,  
asthma  hypertension,  etc.)?    
    Yes           No    
     
If  Yes,  list  the  diagnosis  here:    
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37.)    Do  you  have  inexplicable  pain...no  medical  explanation  for  it?    
    Yes           No    
   
   
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If  Yes,  please  explain:    
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38.)    Do  you  have  difficulty  in  trusting  others?    
    Yes           No    
     
If  Yes,  do  you  know  why?  Please  explain:    
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39.)    Has  there  been  a  death  of  someone  close  to  you?    
    Yes           No      
 
If  so,  whom?   _____________________________________________  
 
40.)    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:   ______________________________  
 
41.)    Do  you  suffer  from  sleep  disorders?    
    Yes           No    
42.)    Any  other  medically  defined  disorder?    
    Yes         No    
     
If  Yes,  please  explain:    
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43.)    Is  there  a  history  of  tuberculosis,  diabetes,  ulcers,  cancer,  heart  disease,  
glandular  problems,  asthma,  other  in  your  family?    
    Yes           No    
     
If  Yes,  please  explain:    
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44.)    Did  you  have  imaginary  friends  as  a  child?    
    Yes           No    
     
If  Yes,  what  were  their  names:    
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45.)    When  attending  Church  or  other  ministries  do  you  have  "foul"  thoughts,  
jealousies  or  other  mental  harassment?    
    Yes           No    
46.)    Do  you  have  difficulty  retaining  God's  Word?    
    Yes           No    
47.)    Difficulty  in  reading  it?  
    Yes           No    
48.)    Do  you  have  migraine  headaches?    
    Yes           No    
49.)    Do  you  have  any  addictions?  
      Yes           No    
50.)    Were  you  ever  diagnosed  with  a  learning  disability  i.e.  (A.D.D.),  etc?    
    Yes           No    
51.)    Do  you  have  a  fear  of  death?    
    Yes           No    
52.)    Have  you  ever  had  suicidal  thoughts?    
    Yes           No    

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53.)    Has  there  been  a  period  of  time  in  your  life  when  you  were  angry  with  God?    
    Yes           No    
54.)    Do  you  have  a  fear  of  losing  your  mind?    
    Yes           No    
55.)    Do  you  suffer  from  anxiety  or  panic  attacks?    
    Yes           No    
If  Yes,  when  and  how  did  they  begin?  
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56.)    Do  you  feel  incredible  loneliness?    
    Yes           No    
57.)    Are  you  plagued  with  doubt  and  unbelief?    
   Yes           No    
58.)    Do  you  feel  inferior?    
    Yes           No    
59.)    Do  you  have  thoughts  of  inadequacy?    
    Yes           No    
60.)    Do  you  have  obsessive  thoughts?    
    Yes           No    
61.)    Blasphemous  thoughts?    
    Yes           No    
62.)    Compulsive  thoughts?    
    Yes           No    
63.)    Lustful  thoughts?    
    Yes           No    
64.)    Do  you  daydream?    
    Yes           No    
65.)    Are  you  a  perfectionist?    
    Yes           No    
66.)    Are  things  seemingly  always  out  of  order?    
    Yes           No    
67.)    Do  you  feel  the  need  to  be  in  control?    
    Yes           No    
68.)    Are  you  rebellious?    
    Yes           No    
 
  10  
  
69.)    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:  
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70.)    Here  are  a  few  symptoms  of  demonic  attack,  please  check  any  symptom  that  
applies  to  you:  
 
o A  compulsive  desire  to  blaspheme  God.  
o A  revulsion  against  the  Bible,  including  a  desire  to  tear  it  up  or  
destroy  it.  
o Compulsive  thoughts  of  suicide  or  murder.  
o Deep  feelings  of  bitterness  and  hatred  toward  others  without  reason:  
Jews,  other  races,  the  church,  strong  Christian  leaders.  
o Any  compulsive  temptations,  which  seek  to  force  you  to  thoughts  or  
behavior  which  you  truly  do  not  want  to  do  or  think.  
o Compulsive  desires  to  tear  other  people  down,  even  if  it  means  lying  
to  do  so.  Vicious  cutting  down  of  others  by  the  tongue.  
o Terrifying  feelings  of  guilt  even  after  honest  confession  is  made  to  the  
Lord.  
o Certain  physical  symptoms  which  may  appear  suddenly  or  leave  
quickly  and  there  are  no  physical  or  physiological  reason.  
o Choking  sensations.  
o Pains  that  seem  to  move  around  and  for  which  there  is  no  medical  
cause.  
o Feelings  of  tightness  about  the  head  or  eyes.  
o Dizziness,  blackouts,  or  fainting  seizures.  
o Deep  depression  and  despondency.  
o Sudden  surges  of  violent  rage,  uncontrollable  anger,  or  seething  
feelings  of  hostility.  
o Terrifying  doubt  of  one's  salvation  even  though  they  once  knew  the  
joy  of  salvation.  
o Seizures  of  panic  or  other  fear  that  is  terrifying.  
o Dreams  or  nightmares  that  are  of  a  horrific  nature  and  often  
recurring.    Clairvoyant  dreams  that  may  even  come  true  are  most  
often  demonic.  
o Abnormal  or  perverted  sexual  desires.  
o Questions  and  challenges  to  God's  Word.  
o Sleep  or  eating  disorders  without  physical  cause.  
o Most  compulsions  and  obsessions.  

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 o Rebellion  and  hatred  for  authority.  
o Bizarre  terrifying  thoughts  that  seem  to  come  from  nowhere  and  you  
cannot  control  them.  
o Fascination  with  the  occult.  
o Involvement  in  criminal  activity.  
o Extremely  low  self-­‐image  (unworthy,  a  failure,  no  good  -­‐  a  constant  
undermining  of  the  self-­‐identity).  
o Constant  confusion  in  thinking  (sometimes  great  difficulty  in  
remembering  things).  
o Inability  to  believe  (even  when  the  person  wants  to).  
o Mocking  and  blasphemous  thoughts  against  preaching/teaching  of  the  
Word  of  God.  
o Perceptual  distortions  -­‐  perceiving  anger,  hostility,  in  others  when  it  
doesn't  really  exist  -­‐  seeing  only  judgment  in  the  scriptures.  
o Horrible  nightmares  causing  fear  (often  having  demonic  images).  
o Violent  thoughts  (suicidal,  homicidal,  encouraging  self-­‐abuse,  etc.).  
o Hatred  and  bitterness  toward  others  for  no  justifiable  reason.  
o Tremendous  hostility  or  fear  when  encountering  someone  involved  in  
deliverance  work.  
o Feelings  of  being  watched  or  sensing  an  evil  presence.  
o Deep  depression  and  despondency  (frequently  and  at  significant  
times).  
o Irrational  fears  -­‐  panic  attacks  -­‐  phobias.  
o Irrational  anger  -­‐  rage.  
o Irrational  guilt  -­‐  self-­‐condemnation  to  the  extreme.  
o Desire  to  do  what  is  right  (inability  to  carry  it  out).  
o Sudden  personality  and  attitude  changes  (severe  contrasts  -­‐  appears  
schizophrenic)  Bi-­‐polar  disorder.  
o A  strong  aversion  toward  scripture  reading  and  prayer  (especially  one  
on  one).  
o 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.  
o Lying,  exaggerating,  or  stealing  compulsively  (often  wondering  why).  
o Drug  abuse  (especially  when  there  is  demonic  hallucinations).  
o Eating  obsessions  -­‐  bulimia,  anorexia  nervosa.  
o Compulsive  sexual  sins  (especially  perversions).  
o Irrational  laughter  or  crying.  
o Irrational  violence  -­‐  compulsion  to  hurt  self  and/or  someone  else.  
o Sudden  speaking  of  a  language  not  previously  known  (often  an  ethnic  
language  of  ancestors).  
o Reactions  to  the  name  and  blood  of  Jesus  Christ  (verbally  or  through  
body  language).  
o Extreme  restlessness  (especially  in  a  spiritual  environment).  
o Uncontrollable  cutting  and  mocking  tongue.  
o Vulgar  language  and  actions.  

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 o 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).  
o Extreme  sleepiness  around  spiritual  things.  
o Demonstration  of  extraordinary  abilities  (either  ESP  or  Telekinesis).  
o Voices  are  heard  in  the  mind  (they  mock,  intimidate,  accuse,  threaten  
or  bargain).  
o Voice  -­‐  refers  to  him/her  in  the  third  person.  
o Supernatural  experiences  -­‐  hauntings,  movement  or  disappearance  of  
objects,  and  other  strange  manifestations.  
o Seizures  (too  long  and/or  too  regular).  
o Pain  (without  justifiable  explanation  -­‐  especially  in  head  and/or  
stomach).  
o Blackouts.  
o Physical  ailments  can  often  be  alleviated  immediately  by  a  command  
of  spiritual  authority  (i.e.  epileptic  seizure,  asthma  attacks,  various  
pains).  
o 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  
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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:   ______________________________________________________  

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