Deliverance Questionnaire

If you are interested in setting up a deliverance appointment, please voulentarilly fill out all pages of the below questionnaire to the best of your ability. By filling this out, you are also acknowedging that should a ministry appointment be scheduled, you will also need to sign our general release agreement before any ministry can take place.

Disclaimer: Filling out this form does not guarantee a ministry appointment.

First Name

Birthday

Is Jesus your Savior?

Yes

Marital Status

Currently Married

Remarried

Not Married

Divorced

Widowed

Last Name

Phone

City

State

Parental Status

Yes I have children 18 years or older

Yes I have children 17 years or younger

I do not have children

I am currently under the care of a:

Psychologist

Psychiatarist

Licensed Therapist

Not Applicable

Ethnic/cultural background: (please be as specific as possible)

Dad's Ethnicity

Do you believe that you are demonically oppressed or possessed and do you want to be set free?

Yes

Mom's Ethnicity

Are you willing to do what it takes to achieve this freedom?

Yes

Do you have any:

Physical Health Issues

Mental Health Issues

Traumatic Occurrence(s)

Are you aware of any unbroken soul ties?

How did you hear about Rebuilt Ruins Ministries? Did somebody refer you to us?

Have you previously received deliverance ministry in the past?

SOCIALS

MANTLE OF PRAISE CONSULTING

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First Name

Last Name

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