Application for Ministry

Please take you time in answering these questions. The information about your life that you share with us will enable us to help you in a more effective way. All information will be kept in strict confidence.

City, State Zip:
Home Phone:
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Questionnaire - All information is confidential and is not stored in any public database in any form.

1) When did you make Jesus Christ your personal Lord and Savior?

2) Has your Christian walk been consistent? If not, why?

3) Name of Church you attend and length of time you have attended there.

4) How often do you attend Church?

5) How much time do you spend reading your bible?

6) Do you have trouble submitting to authority? If yes, in what circumstances?

7) Have you or any of your family members ever been involved in a different religion or belief system other than Christianity?

8) Describe in detail any involvement you have had with the occult, at any level, including books, videos, movies or games?

9) Have you or anyone related to you ever practiced magic, sorcery, witchcraft or satanism? If yes, describe.

10) Have you ever made a pact with the devil, or asked satan/demons for any assistance in your life?

11) Do you currently have in your possession any occultic objects including books (Harry Potter, Twilight etc.), videos, DVDs (even cartoons with magic)or games?

12) Were you or anyone related to you ever involved in Freemasonry, Shriners or Eastern Star?

13) Were you or anyone in your family ever abused either physically, verbally, emotionally, sexually or ritually as a child? If yes, explain.

14) Were you ever abandoned or rejected either by a parent or a spouse?

15) Do you struggle with any addictions including drugs, alcohol, pornography, food, sleep or media?

16) Have you or anyone in your family ever been diagnosed with any mental illness including depression, bipolar, obsessive/compulsive disorder or schizophrenia?

17) Do you have any tatoos? If yes, what are they of?

18) Have you ever had an abortion, or aided in the abortion of a child?

19) Have you ever cut, burned, hit or harmed yourself or felt compelled to do so?

20) Have you ever attempted suicide or struggled with thoughts of it?

21) Is there anyone that you feel that you cannot forgive?

22) Is there anything you have ever done, or that has happened to you, that you are too ashamed to tell anyone?

23) Is there any span of time in your life that you cannot remember?

24) What is your earliest memory and how old were you?

25) What specific demonic manifestations are you experiencing in your life? (ex.seeing into the spirit realm, seeing shadows, feeling a presence, physical attacks, etc)

26) Do you hear voices either inside your mind or outside of you? If yes, what do they say?

27) Have you ever seen a ghost, apparition, angel, demon or an open vision?

28) In what area of your life do you feel you have the greatest level of torment?
For example, this would be in an area that you feel that you have lost control in such as memories from past abuse, uncontrollable rage,etc.

29) Do you believe that you are being tormented by a demonic force?

30) Have you ever been through a deliverance before?

31) What was the outcome?

32) Are you willing to do whatever it takes to get free, including scripture memorization, fasting and making necessary life changes in order to maintain your freedom?

33) Is there anything else you feel we should know about your situation?

34) Are you over the age of 18? If not, do you have permission from a parent or legal guardian to seek help from us?

Check this box if you would like a copy of this questionnaire emailed back to you.