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Application
To apply for a deliverance session, please fill out this form. Please note that filling out this form does not garuntee an appointment.
First Name
Last Name
Email
Phone
Birthday
Is Jesus your Lord and Savior
*
Yes
No
When were you saved?
Address
Marital Status
Single
Married
Seperated
Divorced
Widowed
Parental Status
No Children
Children Under 18 years old
Children Over 18 years old
Have you previously received deliverance/exorcism prayers?
*
Yes
No
Unknown
Describe your relationship with GOD
*
Good
Could Use Improvement
Poor
Were you concieved in or out of wedlock?
*
In
Out
Unknown
Were you adopted?
*
Yes
No
Unknown
Mark all that you have participated in
Astral projection
Astrology / horoscopes
Automatic writing / painting
Animal sacrifice
Fire Walking
Fortune telling
Levitation
Past-life therapy
Psychic consultation
Ouija board
Seances
Spells
Tarot cards
Transcendental meditation
Voodoo
Witch craft / Wicca
Yoga
N/A
Mark books read, practices engaged in, organizations to which you or family members belonged.
Atheism / agnosticism
Bhagavad-Gita (Hinduism)
Buddhism /Zen
Church of Satan / Satanism / Satanic Bible
Dianetics (Scientology)
Edgar Cayce books
Islam / Koran
Jehovah's Witnesses
Kabbalah
Freemasonry
Mormonism
Santeria
Scientology
Voodoo
New Age
Witchcraft
Other
N/A
Please mark any health issues that apply
Cancer
Diabetes
Epilepsy
Gastrointestinal issues
Heart disease
Infertility
PTSD
Other
N/A
Have you or a family been diagnosed with any of the following?
ADD / ADHD
Anxiety / panic disorder
Bipolar
Borderline personality disorder
Depression
OCD
MPD / DID ( multiple personalities )
Schizophrenia
Other
N/A
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