Name:……………………………………………………….Age:………………………

Marital Status:……………………….(Single/Married/Divorced/Widow/Remarried)

Occupation:………………………………………………………………………………

Physical Address:………………………………………………………………………..

Tel. No:……………………………………Cell No:…………………………………….

Name and Tel. No. of close friend or relative:…………………………………………

 

QUESTIONNAIRE FOR THOSE DESIRING DELIVERANCE

 

1. Traumatic Experiences

YES

NO

2. Emotional Problems, conflicts & conditions

YES

NO

At Birth

 

 

Have you suffered from, or been tormented by any-thing in family

 

 

In childhood

 

 

In Relationship

 

 

As Teenager / young adult etc.

 

 

Relationship to other/s

 

 

Of what sort?

 

 

Extreme or abnormal habit /condition

 

 

Are you adopted?

 

 

Rejection / self rejection / fear of rejection

 

 

Sudden death of loved one

 

 

Fear

 

 

Post-operative shock

 

 

Self-pity

 

 

Shock due to accident

 

 

Envy

 

 

Psychic shock

 

 

Pride

 

 

Physical attack

 

 

Jealousy

 

 

With Parents or Family

 

 

Hatred

 

 

Other

 

 

Resentment

 

 

If so, describe below:

 

 

Bitterness

 

 

 

 

 

Thoughts of Suicide

 

 

3. Destructive Habits

YES

NO

Unpredictability

 

 

Lying

 

 

Depression, Worry, Stress

 

 

Blasphemy

 

 

Doubt

 

 

Cursing

 

 

Unbelief

 

 

Smoking

 

 

Self-punishment, mental / physical

 

 

Drinking

 

 

If so, describe below:

 

 

Temper

 

 

 

 

 

Lust

 

 

4. Immoral Conditions

YES

NO

Stealing

 

 

Homo sexuality

 

 

Cheating / Gambling

 

 

Lesbianism

 

 

Constant Criticism / Fault Finding

 

 

Bi-sexuality

 

 

Gossip / Spreading Rumours

 

 

Sodomy

 

 

Gluttony / Bulimia

 

 

Indecent exposure

 

 

Fear (list specific ones)

 

 

Adultery

 

 

Other (list below) :

 

 

Fornication

 

 

 

 

 

Incest

 

 

5. Occult Activity (past or present)

YES

NO

Have desires of the above nature

 

 

Have you ever visited a fortune teller:

 

 

Have pictures / books of the above nature

 

 

They used cards_____, tea leaves_______

 

 

Bestiality (animal type nature)

 

 

palm reading_____, Other_______

 

 

Other (describe below)

 

 

Do you or have you read the horoscope?

 

 

Have you ever sought or been subject to as a child healing?

 

 

Have you ever been hypnotised?

 

 

Through magic conjuration and charming,

 

 

Have you practised self-hypnosis?

 

 

witchcraft, homeopaths, such as:

 

 

Have you practised yoga?

 

 

Removal of warts___burns___disease treated___

 

 

Have you attended a séance?

 

 

Or through a Spiritist___Christian Scientist___

 

 

Have you attended a spiritist meeting?

 

 

Spirit healer___Psychic (faith) healer___

 

 

Have you had a life or reincarnative reading?

 

 

Metaphysical healing___Use of the pendulum___

 

 

Have you ever consulted a ouija board______

 

 

Trance for diagnosis___ or other Occult means:

 

 

a planchette___, Cards, ____Tea leaves_____

 

 

List below:

 

 

Crystal ball____, or other______________?

 

 

Have you ever sought to locate missing persons or

 

 

Have you played with games of occult nature

 

 

objects by consulting someone with psychic,

 

 

such as: ESP____Telepathy____Kabala_____?

 

 

clairvoyant or psychometric powers:

 

 

Other? (List below)

 

 

Have you ever practised table tipping (lifting)___

 

 

Have you, or anyone for you, practised water

 

 

Levitation___Automatic (spirit) writing___

 

 

witching (sometimes called dowsing or

 

 

Have you ever been given or worn an amulet,

 

 

5. Occult Activity (past or present) (cont.)

YES

NO

4. Immoral Conditions (cont.)

YES

NO

divining for water – Using a twig or pendulum?

 

 

talisman or charm for luck or protection?

 

 

Have you had your handwriting analysed?

 

 

Have you ever seen or been involved in Satan

 

 

Have you practised mental suggestion?

 

 

worship?

 

 

Have you cast a magic spell?

 

 

Have you practised any form of magic charming

 

 

Have you sought any psychic experience?

 

 

or ritual?

 

 

Have you practised meditation?

 

 

Have you parents or grand parents been involved in

 

 

Do you have (or have you had) a spirit guide?

 

 

witchcraft/spiritism/fortune telling or free masonry?

 

 

Do you ever hear voices out loud or in your

 

 

Have you or they been involved with witchdoctors

 

 

head?

 

 

sangomas/voocoo/throwing of bones/using sangoma

 

 

7. Occult or Spiritualistic Literature

YES

NO

mutis?

 

 

Do you read or possess literature such as:

 

 

Offering children to the devil/ancestors or ancestral

 

 

Books on astrology?

 

 

worship?

 

 

Interpretation of dreams?

 

 

6. Cults and false religions:

YES

NO

Self-realisation (self-improvement)?

 

 

Have you been involved with any of the following:

 

 

Fortune telling?

 

 

Herbert W. Armstrong

 

 

Magic?

 

 

Hare Krishna

 

 

ESP?

 

 

Scientology

 

 

Clairvoyance?

 

 

Zen Buddhism

 

 

Psychic Phenomenon?

 

 

Beher Baba

 

 

e.g. "Secrets of the Psalms"?

 

 

Hippie-ism

 

 

e.g. the so-called "Sixth or Seventh books of

 

 

Rosicrucians

 

 

Moses"

 

 

Mormons

 

 

Do you possess any occult or pagan religious objects, reli been used in pagan temples and religious cs, or artefacts, which may have rites, or in the practice of sorcery, magic, divinations, or spiritism? If so, list below:

 

 

Christian Scientists

 

 

 

 

 

Baha'i

 

 

 

 

 

The Third Way (Gurdjieff)

 

 

 

 

 

Unity

 

 

 

 

 

Unitarian

 

 

8. A drug user or pusher:

YES

NO

Jehovah's Witnesses

 

 

Are or have you used or been a user or pusher

 

 

TM (transcendental meditation)

 

 

of any of the following

 

 

Unification Church (Moon)

 

 

LSD

 

 

Children of God

 

 

STP

 

 

Theosophy

 

 

Heroin

 

 

Inner Peace Movement

 

 

Mandrax

 

 

Spiritual Frontiers Fellowship

 

 

Methedrine

 

 

Religious Research of America

 

 

Amphetamines (uppers)

 

 

EST

 

 

Nembutal (downers)

 

 

The Way

 

 

Marijuana (dagga)

 

 

Metropolitan Community Church

 

 

Hashish

 

 

MCC (homosexual church organisation)

 

 

THC

 

 

9.General:

YES

NO

Cocaine

 

 

Have you felt an unclean presence near?

 

 

Peyote

 

 

Do you hear voices at night?

 

 

Pain Killers (addiction)

 

 

Do you see strange things at night?

 

 

Glue sniffing

 

 

Does anything or anybody visit you at night?

 

 

Other: list below:

 

 

Do you know (have a premonition) when

 

 

8. Guilt and condemnation:

YES

NO

something bad or evil is going to happen and then

 

 

Do you have guilt and condemnation for: past sins

 

 

find that it does in fact happen?

 

 

Fear of committing the unpardonable sin

 

 

Do you have a problem with night-mares or

 

 

Divorce

 

 

frightening dreams?

 

 

Remarriage

 

 

Do you have unnatural fear for any everyday thing?

 

 

Other: List below

 

 

Have you made a pact or contract

 

 

:

 

 

with the devil

 

 

 

 

 

written in your own blood or in any other way?

 

 

Do you have any physical pain/numbness/tight-

 

 

Have you had sexual experiences with any

 

 

ness/pressure/restriction in your body or in and

 

 

supernatural beings or powers?

 

 

around your head? Constantly or on and off?

 

 

Do you believe that JESUS CHRIST came in the

 

 

What thoughts dominate your thought life? Do

 

 

flesh into the earth to destroy the works of the

 

 

you have re-occurring, bad, ugly, unclean or

 

 

devil?

 

 

predictive dreams? List below:

 

 

 

 

 

 

 

 

 

 

 

INDEMNITY FORM

 

 

 

I, ……………………………., ID. No:…………………………………hereby totally indemnify the counsellor:……………………,I.D. No…………………………from any blame regarding his/her efforts to counsel and help me through prayer and pastoral ministry.

 

I indemnify the above mentioned counsellor regarding any possible legal dispute and action that may ensue because of their efforts on my behalf.

 

I hereby also waiver all my legal rights regarding any litigation with regard to the above mentioned counselling efforts.

 

 

Thus understood and signed at …………….. on this……day of………………..2001

 

 

Signature in full:………………………

 

 

Witness 1:…………………………….

(Signature in full)

 

Witness 2:…………………………….

(Signature in full)

 

 

 

 

 

 

 

 

 

 

Your Personal Experience of the Lord

 

1. Do you belong to a Christian Church? Yes……… No………..

 

Name Minister:………………………………………… Tel. No. ………………………………..

 

2. Have you personally believed in the Lord Jesus for the forgiveness of sins and become born

again? Yes…………. No……………

 

How?………………………………………………………………………………………………..

 

Where?………………………………………………When?………………………………………

 

3. Are you sure of the fact that if you died today that you would be with Jesus in Heaven?

 

Yes………. No……….

 

4. Have you been baptised by full immersion in water? Yes………………No…………………..

 

How?……………………………………………………………………………………………..

 

Where?……………………………………………….When?……………………………………

 

5. Are you filled with or baptised with the Holy Spirit? Yes………… No…………….

 

How?………………………………………………………………………………………………

 

Where?………………………………………………..When?…………………………………….

 

6. Are you satisfied in your walk with the Lord? Yes…………. No……………

 

Give reasons:……………………………………………………………………………………….

……………………………………………………………………………………………………...

 

7. What spiritual activities are you personally involved with for your own personal growth and

where?

Explain:……………………………………………………………………………………………..

 

8. What spiritual ministries are you involved with?

 

Explain:…………………………………………………………………………………………..

……………………………………………………………………………………………………

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Gennesaret Revival Centre

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