check

Intake Form

Must be completed prior to Christian Life Coaching Session with Deliverance.  Answer every question as truthfully as possible, we are here to help, not judge. 

Click the button below to start.

Start

Personal Information

Input your Personal Information. 

            

Question 2 of 22

First Name

Question 3 of 22

Last Name

Question 4 of 22

Age (as of Today)

Question 5 of 22

Email Address

Question 6 of 22

Input City/State/Country

Question 7 of 22

Phone Number (+1 XXX.XXX.XXXX)

Please input your Country Code. Ex: US = +1 for the Country Code. 

Question 8 of 22

Emergency Contact (optional): 

Spiritual Background

The next set of questions are about your Spiritual background. Please be as detailed as possible. 

Question 10 of 22

Do you identify as a Christian?

A

Yes

B

No

C

Other

Question 11 of 22

Have you accepted Jesus as your Lord and Savior? 

A

Yes

B

No

C

Unsure

Question 12 of 22

Have you received deliverance prayer before? 

A

Yes

B

No

C

Unsure

Question 13 of 22

If you answered YES to the above question and have received deliverance before, please provide additional details here. (Dates, Ministry, Experience) (Input N/A if no)

Question 14 of 22

Do you worship, pray, or work with anything spiritually other than God? (Select All That Apply) 

(Select all that apply)
A

Reiki

B

Spirit Guides

C

Other "gods" or deities

D

Ancestors

E

Crystals

F

Sage

G

Chakras

H

Tarot/Astrology/Numerology

I

Other

J

None of the above

Question 15 of 22

Please explain in detail here, if you answered "Other" to the above question about worshipping things other than God. (Input N/A if not applicable)

Question 16 of 22

Current Symptoms or Patterns (Check all that apply)

(Select all that apply)
A

Unexplainable fear or anxiety

B

Nightmares or sleep paralysis

C

Intrusive thoughts or compulsions

D

Chronic sickness with no medical cause

E

Hearing voices or unusual spiritual experiences

F

Addictions or repetitive sin cycles

G

Suicidal thoughts or hopelessness

H

Relational dysfunction / isolation

I

Financial instability or patterns of loss

J

Sexual dysfunction or confusion

K

Other

L

None of the above.

Question 17 of 22

If you selected "Other" for a symptom or pattern not listed please describe in detail here. (Input N/A if none)

Question 18 of 22

Family / Generational History

(Select all that apply)
A

Known witchcraft or occult involvement

B

Freemasonry or secret societies

C

Abuse, trauma, or violence in the home

D

History of addiction (drugs, alcohol, etc.)

E

Mental illness (depression, schizophrenia, etc.)

F

Other religions or spiritual practices

G

None of the above.

Question 19 of 22

Please explain in detail here if you answered yes to the following questions: 

History of addiction/mental illness/other religions or spiritual practices. 

Consent Statement

Please acknowledge consent on the following page by answering yes and inputting your full name. 

Question 21 of 22

"I understand that this session is a Christian spiritual service and not a substitute for therapy or medical care. I voluntarily consent to receive prayer and ministry in accordance with biblical principles.” 

A

Yes

B

No

Question 22 of 22

Please input your First and Last Name along with Today's date here to acknowledge and confirm that you, "understand that this session is a Christian spiritual service and not a substitute for therapy or medical care. I voluntarily consent to receive prayer and ministry in accordance with biblical principles."

Confirm and Submit