Your Name (required)

Your Email (required)

Current Concerns/Disturbances (Health, Relationship, Seeing Things, etc.):

Background Information

 
Father's Name

Mother's Name

Parents background/Involvements (Cult/Occult):

Fathers Side

Grandmother's Name

Background/Involvements (Cult/Occult):

Grandfather's Name

Background/Involvements (Cult/Occult):

Mother's Side

Grandmother's Name

Background/Involvements (Cult/Occult):

Grandfather's Name

Background/Involvements (Cult/Occult):

Please Check any of the following Sickness/Ailments that are Common in the Family (You can Select Multiple Options):

TuberculosisDiabetesHigh BloodHeart DiseaseAsthmaS.T.D.'sShortness of MemoryCancerEye problems (Cataract, etc.)Arthritis, GoutMigraine or HeadacheMental problems
 
Other Sickness/Ailments Common in the Family (not listed)

Curses Pronounced In The Family Line:

---

Personal History

Occult Practices: (Have you participated in any of the following?)

Select all that apply:
ASTROLOGYHOROSCOPE,ZODIACPALM READINGTEA LEAF READINGFORTUNE TELLINGHYPNOSISQUIJA BOARDASTRAL PROJECTIONSEANCES/CHANNELINGLEVITATIONAMULETS (ANKH, CRYSTALS)ACUPRESSURETELEKENESISVOODOOOBEAHWITCHCRAFT / WICCAFAITH HEALINGLATIN PRAYERSNKONDI/NDOKIMAGIC (BLACK OR WHITE)USE OF LOVE POTIONSPYRAMIDOLOGYTONINGACUPUNCTURESHAMANISMKABALAASTROTHERAPYI CHINGHEAVY METALOTHER
 

Cultic Group: (Have you been a member of the following?)

Select all that apply:
TRANSCEDENTAL MEDITATIONP.B.M.A. (PHIL. BENEVOLENTYOGA MISSIONARY ASSOCIATION)BUDDHISM/HINDUISM/SIKH/BAHAISpiritual BaptistBAHALSACRIFICE VALLEYFRATERNITIESSATANISMNEW AGE/THEOSOPHICAL SOCIETYLEGION OF MARYJEHOVAH’S WITNESSHOLY NAME SOCIETYMORMONISMADORATIONRIZALISTASYOUTH MARIAN CURSADESNEW AGE/CHRISTIANSCIENCESMOONIESCHURCH OF CHRIST(IGLESIA NI KRISTO)ISLAM & NATION OF ISLAMRASTAFARIANISMNUWABBIANFREE MASONRYCHILD DEDICATION TO ANY CULTCHILDREN OF GODSCIENTOLOGY/SCIENCE MIND GROUPOTHER
 

Idolatrous Worship: ( makes dedicated prayer, a devotee or made a vow to: )

Select all that apply:
STO .NINOSAN ILDEFONSOLADY OF MANAOAGSAN ISIDROVIRGIN MARIA SALVACIONLADY OF FATIMABLACK NAZARENELADY OF FIATLADY OF PENAFRANCIAST. MICHAEL THE ARCHANGELST. JUDEVIRGEN DOLORESSTA. CLARASTA. RITAHAIL MARYLADY OF EDSASENOR TESOROMOTHER OF PERPETUAL HELPLOURDESST. JAMESSANTA MUERTAOTHER
 

Other Involvements and Experiences:

Select all that apply:
PARTICIPATED IN RITUALS/SACRIFICESDEMONICPOSSESSION/INFLUENCEEVIL SPIRIT GUIDESRECURRING BAD DREAMSCHANGED NAMEBLOOD COMPACTHAVE SEEN DWARF, GHOST, WHITE LADY, EVIL SPIRITSOTHER
 

Spiritual Problems:

Select all that apply:
BACKSLIDINGDIFFICULTY IN BIBLE READINGSPIRITUAL DRYNESSUNFAITHFUL GIVING TO THE LORDPRAYERLESSNESSDIFFICULTY IN PRAYINGIRREGULAR ATTENDING FELLOWSHIPHEARING AND/OR SEEING EVIL THINGSDifficulty Reading BibleOTHER
 

Emotional Experiences Having Difficulty Controlling:

Select all that apply:
FRUSTRATIONFEAR OF HURTING LOVE ONESLONELINESSATTEMPT IN COMMITTING SUICIDEHATREDDEPRESSIONSELF-PITYFEAR, WORRYPRIDEUNFORGIVENESSFEAR OF DEATH, SPIRIT OF DEATHREJECTIONANGERENVYFEELING OF WORTHLESSNESSSTRESSBITTERNESSREBELLIONJEALOUSYLUSTOTHER
 

Mental Experiences: ( In the past, or presently struggling with)

Select all that apply:
DAYDREAMINGCOMPULSIVE THOUGHTSLUSTFUL THOUGHTSHEARING VOICESUNBELIEF / DOUBTSCRITICAL/JUDGEMENTAL THOUGHTSMENTAL BLOCKFORGETFULNESSMPD (MULTIPLE PERSONALITY DIS)SEIZURESCANNOT FOCUSOTHER
 

Physical Involvements/Experiences

A)Addiction/Unusual Craving For (Select all that apply):
SWEETSSMOKINGROCK MUSICSLEEPALCOHOLTV, POCKET BOOKS, VHS, COMICSHORROR MOVIESDRUGS (marijuana, shabu, syrup, cocaine)OTHER
 
B)Other Physical Problems (Select all that apply):
ACCIDENT PRONERECURRING NIGHTMARES OR DISTURBANCESMISCARRIAGE/BARRENESSOTHER
 
C)Sexual Problems: (Select all that apply):
LUSTMASTURBATIONSAME-SEXFORNICATIONRAPEABORTIONFANTASY LUSTINCESTADULTERYSEXUAL ABUSEFRIGIDITY OR SEXUAL COLDNESSPORNOGRAPHYBARRENESSRAPED IN DREAMS (INCUBUS/SUCUBUS)PEDOPHILIAFLASHINGIMMODEST DRESSALLURE THROUGHSENSUAL DRESSOTHER
 
D)Bad Habits (Select all that apply):
LYINGPEEPINGSTEALING OR SHOPLIFTINGUNUSUAL MANNERISMGOSSIPINGTARDINESSLAUNDERINGGAMBLINGOTHER
 
E)Recurring Sickness (Select all that apply):
DIZZINESSALLERGYNERVOUSNESSHEADACHES/MIGRAINEINSOMNIAASHMACOLDNESSPAINOTHER
 
F) Present Relationship Problems (Select all that apply):
MOTHER/FATHERHUSBAND/WIFEFRIENDCHILDRENBROTHER/SISTERIN-LAWSPASTOR/CHURCHMATEOTHER
 
G) Traumatic Experiences (Select all that apply):
RapedAbortionHumiliationMolestedDivorceAbusedBad BreakupDeathOTHER
 

Terms and Conditions (Must Accept)

I agree to not hold Christ's Forgiveness Ministries, or any of its members, mentors, elders or pastors liable for: 1. Services rendered, or for any consequences of such services including counsel, discipleship, declaration of doctrinal beliefs, deliverance, prophecy and healing. 2. Any resulting mental, spiritual, or physical problems resulting during or after the above services including (Should you suffer a heart attack, stroke, paralysis, mental anguish, physical, emotional, or spiritual disability). I hereby give up my right for any recourse, injunctive action, or lawsuit for this attempt to receive counsel, discipleship, deliverance, healing, prophecy and all related services from Christ's Forgiveness Ministries and its members and leaders. I also agree to let Christ's Forgiveness Ministries: 1. Video record the deliverance session and its related services for accountability, case reviews, broadcast, follow-up, deliverance training, and assistance to others in need
I Accept these Terms and Conditions