Questionnaire Form

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This information is voluntary and confidential and does not affect your legibility, for your deliverances. This may assist your deliverances, and your information is confidential.

First Name:_____________________________________

Last Name:_____________________________________






State:________ Zip Code:_______________

Profession:__________________ Do you have a home church? ____ Yes / No____

Are you born again? ___Yes / No___, Am not sure ___, if yes when_____________

Do you want to accept Jesus as your Lord and savior? ____Yes / No____


Catholic __ / Anglican __;  Presbyterian __ / Baptist __; Pentecostal __ / Evangelical __;

Other __; None of the above __; Do you belong to a fellowship __Yes / No__.


How often do you read / Study / Meditate on the Word of God?

Daily __Yes / No__, if yes how often?_____________

Daily, if daily how many minutes at a time?_________

15 Minutes or more? __Yes / No__

For how long in real time?________                                                                                                                          

How many times a week do you meditate on yhe Word of God?_______________

Do you pray? __Yes / No__, If yes for how long?________ How often do you pray?____________

Spiritual Diagnosis:

Do you dream? __Yes / No__

If yes, do you remember your dream vividly? __Yes / No__

Do you Pray? __Yes / No__

If yes, describe briefly features of your dreams:________________________ 





Do you often see yourself:

Eat in your dream? __Yes /No__

Fight in your dreams? __Yes / No__

Sexual activities in your dream? __Yes / No__

Do you See dead relativives in your dream? __Yes / No__

What do you want from this program

Counsel only? __Yes / No__, Deliverance only? __Yes / No__

Counsel and Deliverance? __Yes / No__

Have you undergone any Christian deliverance? __Yes / No__

Is this your first time contacting this ministry physically? __Yes / No__

How did you contact this ministry? By phone __Yes / No__

How did you hear about this ministry?______________________________________

Status: Married __Yes / No__, Single __Yes / No__, Divorced __Yes / No__

How many times have you been married?___________

How many children do you have?_______

Top Ten Questions You Need To Answer.

We are trying to locate the source or root of bondage, these top ten questions can be very helpful and save a lot of time. Think of this as a miniature deliverance questionnaire.

1. What kind of bondage are you facing? Fears, depression, voices in your mind, mental illness, physical illness, mental torment, spiritual torment, financial lack etc.

2. Do you remember when the bondage started? What was happening around the time this bondage started?

3. Can you see any 'open doors' where the bondage may have entered through?

4. Have you or your ancestors been involved in the occult or any false religions? Including secret societies such as Freemasonry and also seeking occult power or knowledge from others, such as having a fortune told, etc.

5. Do you have ancestors or family members who have suffered from a similar kind of bondage?

6. How do you see yourself? (Do you feel guilty, low self-esteem, confident, etc?)

7. Is there anything in your life that has been or is currently troubling you?

8. Do you feel truly loved by God for who you are? (Be honest!)

9. What things have negatively impacted your life? (Traumatic experiences, deeper sins, bad relationships, etc.)

10. What was your relationship with your parents like when you were growing up?



Deliverance Questionnaire

Uncovering open doors to the demonic in a Christian's life

This questionnaire is meant to be used by a knowledgeable deliverance pastor or minister, because the reasons for each of these questions are not explained in this questionnaire. A knowledgeable deliverance minister should know the reasons behind each of these questions, and should be able to discern obvious bondages that these questions will reveal.

Each and every question does not necessarily indicate bondage, but will help give a bigger picture to the person ministering deliverance, and can be helpful in locating obvious bondages in a person's life. These questions can reveal strongholds, demonic bondages and legal grounds that may need to be addressed.

Part I: The bondage

1. When did this bondage start?

2. was there any unusual things that took place (or you did) when this bondage started?

3. If this bondage started when you were a child: Do you have ancestors who have suffered from a similar kind of bondage?

4. What kind of bondage are you facing? (Fears, depression, voices in your mind, mental illness, physical illness, mental torment, spiritual torment, etc.. Please be as detailed as possible.)

5. What are all the things that have impacted your life? (Parent's death, trauma, a certain situation that changed your life, anything that 'changed' you.)

Part II: Your ancestor's background

1. Do you have ancestors who have struggled with similar problems or bondages?

2. Did your bondage start as a child and appear to have no reason to be there?

3. Do you have siblings who suffer from similar bondages or oppression?

Part III: Soul ties

1. Have you been involved with extramarital sex? Are you attracted to an ex-lover? Is he or she a good/godly influence for you?

2. Have you been divorced?

3. Do you feel an unusual attraction to a past boyfriend, girlfriend or lover (who is obviously not right for you)?

4. Do you let anybody dominate, control, or make your choices for you?



5. Have you ever formed a blood covenant with another person? (Blood brothers, etc.)

6. Have you ever made vows or agreements with somebody in effort to strengthen the relationship or commit yourself to each other?

7. Do you see any ungodly relationships in your past where gifts were exchanged? (Are you holding onto something that was given to you from somebody you had adultery with, etc.)

8. Have you ever had ungodly relations with an animal?

9. Do you have any pictures in your possession of somebody whom you may have an ungodly soul tie with? (A picture of you with somebody you had an adultery with, etc.)

Part IV: Relationship with parents

1. What do you think of your parents?

2. How would you explain your childhood?

3. Where you close to your parents while growing up? If not, why?

4. How would you explain your relationship with your parents? Was it good, bad or very cold?

5. Did you feel rejection from your parents?

6. Was either of your parents overly passive or controlling?

7. Has either of your parents been divorced? Remarried? Are your parents divorced?

8. How would you describe your relationship with your siblings growing up?

Part V: Rejection and abuse

1. Were your parents married when you were conceived? Were you the right sex? Did your parents not want you, or want you to be different (gender, etc.) in any way? If so, explain.

2. Did you feel rejected as a child, or as an adult? If so, whom? Explain.

3. Did you face abuse? What kind (emotional, physical, sexual, etc.) and by whom?

4. Have you faced rejection from your peers, classmates, friends or those around you?

5. Have you ever been put down, belittled, or made fun of? If so, whom? Explain.

6. If you have faced rejection or abuse, how did you respond? Do you feel you are still paying a price for it? If so how?

7. How do you respond to rejection right now?

8. Do you reject yourself (self-rejection)? If so why and in what ways?



Part VI: Unforgiveness or Bitterness

1. Is there anybody you feel edgy around? (Don't like them, feel anything in your heart against them, etc.)

2. Are you bitter or have anything against anybody?

3. Has anybody wronged you that you haven't forgiven from your heart (thoughts, feelings, emotions, etc.)?

4. How do your view your siblings, parents, coworkers, etc.? Do you have any hard feelings against them?

5. Do you make a habit of blaming yourself for everything? Do you obsess over your mistakes and feel unusually guilty for them?

Part VII: Personality

1. Are you a very positive or negative person?

2. Do you feel confident in yourself? If so why?

3. Do you have a low self esteem? If so why?

4. Are you domineering or controlling? If so whom and in what ways and why?

5. Are you an achiever?  Or a go-getter, in what ways?

6. Do you feel that you are always right and that if everybody did everything your way, this world would be a better place to live?

7. How do you treat your children? Husbands are you controlling, passive, etc.?

Part VIII: Emotional health

1. Do you strive to feel accepted? If so, how does this affect your lifestyle? By whom do you want to feel accepted?

2. Are you always stressed out? If so why?

3. Do you feel hurt?  By whom; and why?

4. Do you feel good about yourself? If not, why?

5. Do you feel depressed? If so why? When did it start? Did your parents or grandparents struggle with depression? If so, then do you know when it started and why? Do you have siblings who are also struggling? Do you feel your depression is rational or irrational?

6. Do you struggle with fears? If so in what ways? (Fear of heights, dying, being hopeless, failure, never marrying, etc.)

7. Do you worry about things? What things do you worry about? Why?



8. Do you struggle with anger? Do you have a short temper?

9. Do you have any insecurity? If so, explain.

10. Do you feel any self-pity or feel sorry for yourself? Have you ever felt this? If so, why?

11. Do you find it easy to hate people? If so, over what kinds of things would a person have to do to make you hate them?

12. Do you have any irrational feelings? If so, what are they?

13. Do you feel like something is wrong with you?

14. Do you feel excessively guilty over anything? Is this a continual problem?

15. Are you very confused and forgetful? (Beyond the normal)

16. Are you aware of any emotional wounds that have affected you?

17. Have you ever been deeply embarrassed over something? What was it?

Part IX: Who are you in Christ? And how do you see God?

1. How do you explain your relationship with God?



2. Do you feel you aren't good enough to meet His standards?

3. Do you see Him as a loving father, or a dictator?

4. Do you believe that it's only by the Blood of Jesus that your sins are forgiven? Or do you feel you need to earn your forgiveness in any way?

5. Do you feel God's love in your life?

6. Do you feel like your sins are forgiven? Or do you feel guilty?

7. Do you feel excessively guilty in everyday life?

8. Do you feel that doing good things, you earn God's love and acceptance?

9. Do you feel that God is angry or upset with you?

Part X: Spoken curses, vows & oaths

1. Have you ever spoken something negative about yourself that has come to past? For example: "I'm sick and tired..." or "If I don't quit typing, I'm going to get arthritis!"

2. Has your parents, or those in authority over you spoken out a curse over you? For example: "You'll never amount to anything!" or "You'll never get out of debt" or "You're so dumb"

3. Have you ever made a vow out of anger? If so, what? For example: "I'll never let anybody push me around again!" or "I'm never going to be hurt again!"

4. Have you ever wished to die? Have you ever said it?

5. If you have made any vows or oaths, what are they?

Part XI: Relationships

1. Do you have many friends? What kind of people are they?

2. Do you have a hard time trying to meet new people or make friends?

3. Are you socially outgoing or shy? If so, why?

4. How would you define your relationship with your spouse?

Part XII: Sexuality

1. Have you ever had unholy sex? What kind? (Fornication, Adultery, Sodomy, Bestiality, with a child, etc.)

2. Have you struggled with lust, fantasy or unholy sexual thoughts? If so, what kind?

3. Have you been attracted to pornography?

4. Do you have homosexual thoughts and desires? If so, have you acted upon those feelings?

5. How do you feel about your sexuality? (Do you feel dirty about it, or do you feel it's a wonderful blessing that God's given you?)

6. Do you withhold sex from your spouse or are you fidgety? Do you enjoy a healthy relationship with your spouse sexually? How does he or she react?

7. Have you ever been raped or sexually abused?

8. Have you ever woke up and felt a sexual presence with you? There are demons that imitate male and female functions, and stimulate their host (a person) sexually (beyond the normal 'wet dream').

9. Do you struggle or have you struggled with masturbation?

10. Do you struggle or have you struggled with any other sexual related thoughts, desires, or bondages?

Part XIII: Addictions

1. Do you have any addictions? If so, what kind? (Drugs, alcohol, smoking, eating, sex, TV, etc.) When did they start?



2. Did anybody else in your family (siblings, ancestors, etc.) have a struggle with any addictions? If so, what? Who?

3. Have you ever had, or currently have any sort of obsession over anything? If so, what?

Part XIV: False religions

Examples of false religions: Buddhism, Hindu, Jehovah Witness, Mormonism, Christian Scientists, eastern religions, etc.

1. Have you ever been involved with any false religions? If so, why, when and how long? How do you feel about those beliefs now?

2. Have you ever been involved in any secret societies such as Freemasonry? If so, how deep were you involved?

Part XV: The Occult & Satanism

1. Have you ever shown interest in the occult? If so, in what ways? (Read up on it, dabbled in it, etc.)

2. Do you still feel drawn or attracted to the occult?

3. Have you had any interest in horror or thriller style movies or novels? Are you still attracted to these things?

4. Have you ever made a vow with the devil? If so, what?

5. Married Satan?

6. Worshipped a demon or Satan?

7. Have you ever put a curse or spell on somebody?

8. Are you aware of any curses or spells placed on you? If so what? Who did it?

9. Dabbled with an Ouija board? If so, why?

10. Ever been a member of a coven (group of 13 witches)? Explain.

11. Communicated with the dead? Explain.

12. Told somebody's fortune or went to see a fortune teller? Explain.

13. Ever read your horoscope?

14. Watched or been involved in a séance? Explain.

15. Been involved or a victim of Satanic Ritual Abuse (SRA)? Explain.

16. Been baptized into a false religion or any other evil baptism? If so, what were you baptized into? When?

17. Have you ever had a spirit guide?

18. Have you ever been involved with meditation, yoga, karate, or related activities?

19. Were you or anybody in your family superstitious? If so, who?

20. Ever been involved in astral travel? (Out of body)

21. If you have made any vows or oaths, what are they? Were there any sacrifices or a ritual that was accompanied with them?

22. Have you ever made a blood pact before? If so, with whom (including persons, demons and Satan) and for what purpose?

23. Have you ever partaken in automatic writing, automatic drawing or automatic painting?

24. Have you ever been involved in Yoga, transcendental meditation, or similar activities?

25. Have you ever sought healing from a spiritual source other than Jesus Christ? (New age healing, energy healing, etc.)

26. Any other involvement in the occult? Explain.

Part XVI: Un-confessed sins

1. Are there any un-confessed sins that you have not repented of? (Usually something you've done, that you know is wrong, but won't admit to it. An abortion, stealing, etc. are some examples.)

2. Is there anything you've been hiding inside that you haven't confessed?

3. Do you feel excessively guilty over some thing(s) you've done in the past? If so, what?

Part XVII: Cursed objects

1. Do you have any idols, occult rings, or anything that could hold evil spiritual value in your home? If so, what? Any objects that hold evil spiritual value must be destroyed.

2. Do you have any gifts saved from sinful relationships? If so, explain. For example, if a man gives a woman a personal gift during an adultery that needs to be sold or destroyed.

Part XVIII: Severe trauma, abuse & disassociation

1. Have you ever been exposed to extreme abuse or a traumatic experience? Did it have a drastic effect on your emotional or mental system? If so, what happen? How did it affect you?

2. Have you ever disassociated or been diagnosed with Dissociative Identity Disorder (DID) or Multiple Personality Disorder (MPD)?

3. Are you aware of any alters (other personalities) that you may have? (If so, tell me about them)



4. Do you have a memory gap where you cannot remember a certain time of your life?

5. Do you have false memories of things that really didn't take place?

Part XIX: Weaknesses

1. Do you struggle with any habitual sins? If so, what? Do you want to break those bad habits?

2. Do you struggle with any weaknesses such as lust, anger, hate, etc.? If so, what? Do you know where they came from or how they got started? Do you want to break free from those weaknesses?

Part XX: Pregnancy issues

1. Have you ever said something along the lines of, "I will never have children"?

2. Have you ever had an abortion or attempted one?

3. Have you ever had incest or ungodly sexual relations with somebody related to you? (See Leviticus 20:19-21, as this can cause a curse to land upon you which needs to be broken)

Part XXI: Other things to look for

1. Have you ever tried drugs? If so, how much, and how did it affect you? Why did you try drugs?

2. Have you ever thought about or attempted suicide?

3. Do you have any physical or mental disabilities, diseases or illnesses? Explain.

4. Do you want, and are willing to be delivered? Are you willing to give up those demon spirits and maybe make some lifestyle changes in order to keep your deliverance?

5. Do you experience unusual confusion settle upon you as you try to pray and read the Bible?

6. What kind of music do you like? (Please list all styles of music you currently enjoy, and give examples in each category you list, such as some names of artists and songs)

7. Have you previously enjoyed hard rock, metal, acid, alternative, rap, new age, or any other kind of worldly music? (Please provide some examples of artists and songs from each genre (type/style) of music you list)

8. Have you had any nightmares or weird experiences at night while supposedly sleeping?

9. Have you ever been in a trance or had an out of body experience?

10. Have you ever noticed time slipped right out from under you? For example, you look at your watch and it's 7:00pm, then you look again what seemed like 15 minutes later and it's 2:00am. This is a sign of a trance.

11. Have you ever had any other kind of weird encounter with the spiritual realm?