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Your Deliverance Information

This form provides a comprehensive and sensitive approach to assessing the spiritual needs of both Christians and non-Christians. It respects individual beliefs while guiding the deliverance process with clear, targeted questions.

Full Name *

Age *

Email Address *

Date of Birth

Gender *

Phone Number *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

--- Select country ---AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountry

1. Marital Status: *

• Single
• Married
• Widowed
• Divorced

please Age participated

2. Religious Background:

• Christian
• Non-Christian

If Non-Christian, please specify Religion/Belief System:

3. Are you currently affiliated with a church or religious group?

• Yes
• No

If yes, please specify:

Section 2: Spiritual and Emotional Well-being

1. What are your primary concerns that led you to seek deliverance? *

2. Have you experienced any of the following? (Check all that apply) *

• Nightmares or disturbing dreams
• Unexplainable fears or phobias
• Hearing voices or seeing visions
• Persistent negative thoughts
• Physical ailments with no medical explanation
• Feelings of being cursed or hexed
• Unexplained accidents or misfortunes
• Addictions (e.g., substance abuse, gambling)
• Emotional disturbances (e.g., depression, anxiety)
• Unusual or erratic behavior
• Family history of occult involvement or curses
• Involvement in occult practices or other religions

Other (Please specify):

3. On a scale of 1 to 10, how would you rate your overall spiritual well-being? *

4. Have you sought spiritual or emotional help before? *

• Yes
• No

If yes, please describe the experience:

5. Are you currently undergoing any medical or psychological treatment? *

• Yes
• No

If yes, please describe the experience

6. Are you currently undergoing any spiritual Attacks *

• Yes
• No

If yes, please describe the experience and how long you have been facing the situation

Section 3: Christian-Specific Questions (If applicable)

1. How would you describe your relationship with God? *

2. How often do you engage in the following spiritual activities? (Check all that apply) *

• Prayer
• Reading the Bible
• Worship
• Fasting
• Fellowship with other believers

3. Have you ever experienced spiritual deliverance before? *

• Yes
• No

If yes, please describe the experience:

4. Do you feel any resistance or fear when you think about God or Jesus Christ? *

• Yes
• No

If yes, please describe the experience:

Section 4: Non-Christian Specific Questions (If applicable)

1. What spiritual or philosophical beliefs guide your life? *

2. Have you ever participated in any form of spiritual cleansing or deliverance in your tradition?

• Yes
• No

If yes, please describe the experience:

3. Are you open to receiving spiritual guidance or prayer from a Christian perspective? *

• Yes
• No

4. Do you have any concerns or reservations about participating in a Christian deliverance session? *

• Yes
• No

If yes, please specify: *

Section 5: Consent and Declaration

1. I understand that the deliverance process may involve spiritual guidance, prayer, and other religious practices. *

• Yes
• No

2. I consent to participate in the deliverance process, and I understand that this is a spiritual exercise, not a substitute for medical or psychological treatment. *

• Yes
• No

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