Phone number *
Phone type Mobile Home Work Other
Were you the first child born to your parents? *
Are you are Born Again Christian? *
Are you aware of ancestor involvement in any of the things listed below? If so, please explain. *
Exodus 34:7 says that God “visits the iniquity of the fathers on the children and the children’s children to the third and fourth generation.” This means that the sin of your family line can impact you. The next six questions seek to understand if this may be true in your life.
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.? *
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? *
Any sexual abuse, or sexual embarrassment through childhood? *
Any physical, verbal, or emotional abuse from parents or others? *
Do you recall any spoken words from parents or others that were condemning? Any embarrassing or humiliating experiences at school or from school teacher? *
Such as "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.”
Involvement (however innocently it may have been) with Ouija Boards, Magic 8 Ball, levitation games, seances, fortune tellers, tarot cards, astrology, or horoscopes? *
Please list accidents or injuries that come to your mind as being frightening to you at the time: *
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? *
Periods of, or habitual immorality? (including pornography, sexual fantasy, promiscuity, etc. *
Drinking and/or drug use? *
Do you experience unusual fears? *
Do you have people in your life you are bitter and unforgiving towards? *
What do you think may be the areas of demonic influence in your life? *
Are your parents divorced? *
Unusual feelings such as: Never really felt loved, couldn't please my father/mother, feelings of worthlessness, etc.? *
Have you been exposed to pornography? *
If Yes, how old were you? *
Feelings of guilt and shame? *
Fatigue without medical reason? *
Have you had an abortion? *
Do you experience feelings of self-hate? *
Have you suffered from self-harm? *
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.
If yes, please explain. *
Have you ever "felt" a presence in the room? *
If yes, has it been recently? *
If yes, please explain. *
Do you have nightmares or hear voices in your head? *
If yes, please explain. *
Do you have any ongoing physical or mental medical conditions diagnosed by a doctor? *
If yes, list the diagnosis here: *
Do you have inexplicable pain with no medical explanation for it? *
If yes, please explain. *
Has there been a death of someone close to you? *
Do you feel like you have any eating disorders? *
Do you suffer from sleep disorders? *
Is there a history of a specific disease that multiple people from different generations have within your family? *
If yes, please explain. *
Have you ever had suicidal thoughts? *
Do you suffer from anxiety or panic attacks? *
If Yes, when and how did they begin? *
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