Note:  denotes a required field.
	Your Name  (First MI. Last):	Mr. Mrs. Miss    .
	Spouse's Name:	(put None if needed)
	Prior Marriages?:	Yes   No
	If so, how many?:
	Your Street/PO Box:
	City:		State: ABAKALARASAZBCCACOCTDCDEFLGAGUHIIAIDILINKSKYLAMAMBMDMEMIMNMOMSMTNBNCNDNENFNHNJNMNSNTNUNVNYOHOKONORPAPEPRQCRISCSDSKTNTXUTVAVIVTWAWIWVWYYT
	Zip:
	Your Phone #:
	Your Fax #:
	Your Email Address:
	Names of Children:	(put None if needed)
	Date of Birth:
	Were you the first born?:	Yes   No
	Father's Surname:
	Mother's Surname:
	Are you saved?:	Yes   No
	Where and approximately what age?:
	How did you hear about this ministry?:
	Best Time To Meet:
	Today's Date:	02/04/2012

Aware of ancestor involvment in any of these?:  Yes   No

If Yes, explain:

From birth and your early childhood: Trauma during pregnancy by your mom or dad, divorce, words of "We shouldn't be having this child", etc.?
If Yes, explain:
Early childhood fears, injuries, nightmares, see things in your room, felt evil presence?:
If Yes, explain:
Any sexual abuse, or sexual embarrassment through childhood?:
If Yes, explain:
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?:
If Yes, explain:
Any physical abuse from parents or others?:
If Yes, explain:
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.?:
If Yes, explain:
Please list accidents or injuries that come to your mind as being frightening to you at the time:
Please list surgeries and approximate age:
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?:  Yes   No
Periods of immorality?:
If Yes, explain and specify ages:
Drinking and/or drug use?:
If Yes, explain and specify ages:
Do you experience unusual fears?:  Yes   No
If Yes, explain:
What do you think may be the areas of demonic influence in your life?:
Problems in home?:
If Yes, explain:
Are your parent's divorced?:  Yes   No
If Yes, how old were you?:
Unusual feelings such as: Never really felt loved, couldn't please my father/mother, feelings of worthlessness, etc.?:
If Yes, explain:
Exposed to pornography?:  Yes   No
	If Yes, how old were you?:

Please answer the following questions as they apply to your life:
Homosexual tendencies?:	Yes   No
Participated in college fraternities or sororities?:	Yes   No
Feelings of guilt and shame?:	Yes   No
Hopelessness?:	Yes   No
Fatigue without medical reason?:	Yes   No
Abortion?:	Yes   No
Difficulty in forgiving?:	Yes   No
Is there bitterness, anger, or unforgiveness?:	Yes   No
If so, can you forgive?:	Yes   No
Do you hate yourself?:	Yes   No
Have you suffered from self harm?:	Yes   No
Do you have feelings of gloom?:	Yes   No
Do you feel rejected?:	Yes   No
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 artifacts, wiccan, etc.?:
	Yes   No
If Yes, can you give examples?:
Ever "felt" a presence in the room?:	Yes   No
If Yes, has it been recently?:	Yes   No
If either question was Yes, please explain:
Do you have nightmares?:	Yes   No
If Yes, do you hear voices?:	Yes   No
If either question was Yes, please give an example:
Have you been diagnosed by a doctor as having: (list any diagnosis, diabetes, asthma hypertension, etc.)?:	Yes   No
If Yes, list the diagnosis here:
Do you have inexplicable pain...no medical explanation for it?:	Yes   No
If Yes, please explain:
Do you have difficulty in trusting others?:	Yes   No
If Yes, do you know why? Please explain:
Has there been a death of someone close to you?:	Yes   No
If so, whom?:
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:
Do you suffer from sleep disorders?:	Yes   No
Any other medically defined disorder?:	Yes   No
If Yes, please explain:
Is there a history of tuberculosis, diabetes, ulcers, cancer, heart disease, glandular problems, asthma, other in your family?:
	Yes   No
If Yes, please explain:
Did you have imaginary friends as a child?:	Yes   No
If Yes, what were their names:
When attending Church or other ministries do you have "foul" thoughts, jealousies or other mental harassment?:	Yes   No
Do you have difficulty retaining God's Word?:	Yes   No
Difficulty in reading it?:	Yes   No
Do you have migraine headaches?:	Yes   No
Do you have any addictions?:	Yes   No
Were you ever diagnosed with a learning disability i.e. (A.D.D.), etc?:	Yes   No
Do you have a fear of death?:	Yes   No
Have suicidal thoughts?:	Yes   No
Has there been a period of time in your life when you were angry with God?:	Yes   No
Do you have a fear of losing your mind?:	Yes   No
Anxiety or panic attacks?:	Yes   No
If Yes, when did they begin?:
Do you feel incredible loneliness?:	Yes   No
Are you plagued with doubt and unbelief?:	Yes   No
Do you feel inferior?:	Yes   No
Do you have thoughts of inadequacy?:	Yes   No
Do you have obsessive thoughts?:	Yes   No
Blasphemous thoughts?:	Yes   No
Compulsive thoughts?:	Yes   No
Lustful thoughts?:	Yes   No
Do you daydream?:	Yes   No
Are you a perfectionist?:	Yes   No
Are things seemingly always out of order?:	Yes   No
Do you feel the need to be in control?:	Yes   No
Are you rebellious?:	Yes   No
Insecurity? (On a scale of 1-10 with 10 being worst)?:
Please explain:
Note:  denotes a required field.

Here are a few symptoms of demonic attack, please check any symptom that applies to you:

A compulsive desire to blaspheme God. A revulsion against the Bible, including a desire to tear it up or destroy it. Compulsive thoughts of suicide or murder. Deep feelings of bitterness and hatred toward others without reason: Jews, other races, the church, strong Christian leaders. Any compulsive temptations which seek to force you to thoughts or behavior which you truly do not want to do or think. Compulsive desires to tear other people down, even if it means lying to do so. Vicious cutting by the tongue. Terrifying feelings of guilt even after honest confession is made to the Lord. Certain physical symptoms which may appear suddenly or leave quickly and there are no physical or physiological reason. Choking sensations. Pains which seem to move around and for which there is no medical cause. Feelings of tightness about the head or eyes. Dizziness, blackouts, or fainting seizures. Deep depression and despondency. Sudden surges of violent rage, uncontrollable anger, or seething feelings of hostility. Terrifying doubt of one's salvation even though they once knew the joy of salvation. Seizures of panic or other fear that is terrifying. Dreams or nightmares that are of a horrific nature and often ...recurring. Clairvoyant dreams that may even come true are most often demonic. Abnormal or perverted sexual desires. Questions and challenges to God's Word. Sleep or eating disorders without physical cause. Most compulsions and obsessions. Rebellion and hatred for authority. Bizarre terrifying thoughts that seem to come from nowhere and you cannot control them. Fascination with the occult. Involvement in criminal activity. Extremely low self-image (unworthy, a failure, no good - a constant undermining of the self-identity)./li> Constant confusion in thinking (sometimes great difficulty in remembering things). Inability to believe (even when the person wants to). Mocking and blasphemous thoughts against preaching/teaching of the Word of God. Perceptual distortions - perceiving anger, hostility, in others when it doesn't really exist - seeing only judgment in the scriptures. Horrible nightmares causing fear (often having demonic images). Violent thoughts (suicidal, homicidal, encouraging self-abuse, etc.). Hatred and bitterness toward others for no justifiable reason. Tremendous hostility or fear when encountering someone involved in deliverance work. Feelings of being watched or sensing an evil presence. Deep depression and despondency (frequently and at significant times). Irrational fears - panic attacks - phobias. Irrational anger - rage. Irrational guilt - self-condemnation to the extreme. Desire to do what is right (inability to carry it out). Sudden personality and attitude changes (severe contrasts - appears schizophrenic) Bi-polar disorder. A strong aversion toward scripture reading and prayer (especially one on one). 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 your directly. Lying, exaggerating, or stealing compulsively (often wondering why). Drug abuse (especially when there is demonic hallucinations). Eating obsessions - bulimia, anorexia nervosa. Compulsive sexual sins (especially perversions). Irrational laughter or crying. Irrational violence - compulsion to hurt self and/or someone else. Sudden speaking of a language not previously known (often an ethnic language of ancestors). Reactions to the name and blood of Jesus Christ (verbally or through body language). Extreme restlessness (especially in a spiritual environment). Uncontrollable cutting and mocking tongue. Vulgar language and actions. 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). Extreme sleepiness around spiritual things. Demonstration of extraordinary abilities (either ESP or Telekinesis). Voices are heard in the mind (they mock, intimidate, accuse, threaten or bargain). Voice - refers to him/her in the third person. Supernatural experiences - hauntings, movement or disappearance of objects, and other strange manifestations. Seizures (too long and/or too regular). Pain (without justifiable explanation - especially in head and/or stomach). Blackouts. Physical ailments can often be alleviated immediately by a command of spiritual authority (i.e. epileptic seizure, asthma attacks, various pains). 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.

Additional Comments:

           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 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 occultic activities they must be renounced. Typical prayer:

           "Father, I denounce 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 and choose to be free in Jesus Christ' Name. Amen"

Directions To Office: From Highway 121N take the Glade Road exit and go west on Glade to Highway 26 (Colleyville Blvd) Left on Colleyville Blvd one short block to Vineyards Antique Mall, 4701 Colleyville Blvd. Colleyville, TX 76034. Our offices are in the rear of the store (Phone #: 817-581-8860). PRAYER MAKES THE DIFFERENCE!