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Personal Information
Your Name
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Your City and State
Referred By
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Your Age
Your Country of Birth
Have you ever lived outside the US?
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Have you or are you currently seeing a counselor?
Yes
No
Do you need physical healing?
Yes
No
Briefly describe any previous inner healing or deliverance you have received in the past.
What are the reasons you have decided to seek prayer?
Family Information
Please list the 1) First Name; 2) Age (or Age when Deceased); 3) Country of Birth (if not the US); and 4) Faith for each family member below:
Mother
Father
Stepmother
Stepfather
Mother's Mother
Mother's Father
Father's Mother
Father's Father
Siblings (1 per line)
Spouse (1 per line, if previous marriages)
Children (1 per line)
Personal History
Were you a planned child?
Do Not Know
Yes
No
Were you the “right” sex?
Do Not Know
Yes
No
Were you adopted?
Do Not Know
Yes
No
Were you conceived out of wedlock?
Do Not Know
Yes
No
Describe any complications or traumas your mother experienced during pregnancy or your birth?
Have you had any miscarriages or abortions? If yes, please list your age and “M” or “A.” Do the same for all females in your family line.
Did you have any traumatic experiences growing up? If yes, please briefly describe.
Were or are any of the following present in your family… Adultery, Addictions, Abuse (sexual, verbal, emotional, physical or spiritual)? Briefly describe who was involved.
List any current or past physical health problems. Do any of these run in your family and if so, who?
Have you experienced any of the following… Depression, Anxiety, Fear, Inferiority, Insecurity, Feel like a failure, Don’t like yourself? If yes, does this run in your family and who?
Do you currently hold any of these emotional responses toward anyone… Unforgiveness, Resentment, Bitterness, Anger or Hatred? Briefly describe who and why.
Have you or a family member ever committed or attempted suicide? Briefly describe who and why.
Have you ever experienced loud thoughts or voices in your head?
Yes
No
Have you or a family member ever participated in the following …
Buddhism, Zen, Christian Science, Hinduism, Islam, Jehovah’s Witnesses, New Age, Religious Science, Scientology, Unitarianism, Freemasonry (Eastern Star, Job’s Daughters, Rainbow Girls, Shriners, Eagles, Elks), Astral Projection, Ouija Board, Clairvoyance, Fortune Telling, Mediums, Tarot Cards Palm-Reading, Astrology, Transcendental Meditation, Spirit Guides, Witchcraft, Dungeons & Dragons, Hypnosis, Seances?
Please list any and note if (S)elf or (F)amily member.
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