Freedom Ministry Application
Please complete as best as you can. Some of it may be difficult, but it will be helpful during your ministry session.
Personal Information
First Name
Last Name
Phone Number
Address
Apartment, suite, etc.
City
State
Zip/Postal Code
Birthdate
Month
January
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December
Date
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Year
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2015
2016
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2018
2019
2020
2021
2022
2023
2024
Gender
Male
Female
I'd rather not say
Marital Status
Single
Married
Widowed
Separated
Divorced
I'd rather not say
IF you have children, what are their ages?
What church do you attend?
Are you saved?
Yes
No
I don't know
Have you read the book When Pigs Move In, by Don Dickerman?
Yes
No
History
It is not necessary to go into detail with your responses unless requested.
Father's last name & ancestors country of origin:
Mother's last name & ancestors country of origin:
Were any of your ancestors invovled in ay of the following (check all that apply)?
Freemasonry
Eastern Star
Rainbow Girls
Oddfellows
Rebecca Lodge
Other
Please briefly explain if any of the above are checked.
Ask the Holy Spirit to show you any area of concern from birth/early childhood (trauma during pregnancy) by Mom or Dad, divorce, etc.
Early childhood fears, injuries, nightmares, see things in your room, felt evil presence, etc.
Any sexual abuse or sexual embarrassment as a child?
Yes
No
Any spoken words from parents or others that were received as condemnation and/or embarrassing or humiliating experiences at school or from a school teacher
Any physical abuse from parents or others?
Involvement (however innocently it may have been) with:
Ouija Board
Magic 8 Ball
Levitation Games
Seances
Fortune Tellers
Tarot Cards
Astrology
Horoscopes
Fascination with books about magic
Psychics/Seers
Harry Potter Books
Pokemon Cards
Please explain anything checked above.
Please list any accidents or injuries that come to your mind as being frightening to you at the time.
Please list any surgeries and your approximate age at the time.
The purpose of this form is to help determine possible entryways for evil spirits... Obviously, generational/ancestral permission, as forewarned in Exodus 20:5, is a possibility in anyone's life. There are 30 ancestors in your history that could have passed a spirit on to you. Likely, you only know about your parents and each of their two parents.
Please give any information that the Holy Spirit brings to your mind. And please identify which side of the family.
Have you experienced in the past, or do you currently experience (please select all that apply):
Problems in the home
Parents divorced
Lack of feeling loved
Feel/felt like I could never please my parents
Feel/felt worthless
Pre-marital sex
Periods of immorality
Alcohol and/or drugs
Unusual fears
Pornography
Homosexual tendencies
Fraternities/Sororities
Feelings of guilt or shame
Hopelessness
Fatigue w/out medical reason
Abortion
Unusual bouts with anger
Difficulty in forgiving
Self-hate
Self-harm
Feelings of gloom
Feelings of rejection
Do you have any objects in our home or possessions that relate to ungodliness or cults. This would include new age religions, such as books about eastern deities, crystals, heavy metal music, Native American artifacts, Wiccan, etc.
Yes
No
Please explain.
Do you have nightmares?
Yes
No
Do you hear voices?
Yes
No
Please describe.
Please list any medical diagnosis given by a doctor.
Do you have inexplicable pain with no medical explanation for it?
Yes
No
Please describe this pain.
Do you have difficulty trusting others?
Yes
No
Do you know why?
Have you experienced the death of someone close to you?
Yes
No
Who?
Do you feel you have any eating disorders?
Yes
No
Please explain why you feel like you have an eating disorder.
Any sleep disorders?
Yes
No
What type?
Family medical history. (diabetes, heart disease, cancer, asthma, etc.)
Did you have imaginary friends as a child?
Yes
No
Please describe the imaginary friend/friends.
When attending church, or other ministries, do you have "foul thoughts", jealousies, or other mental harassment?
Yes
No
Please describe this mental harassment.
Do you have difficulty retaining God's Word?
Yes
No
Have migraine headaches?
Yes
No
Struggle(d) with addictions?
Yes
No
Have a fear of death?
Yes
No
Have struggled with suicidal thoughts?
Yes
No
Has there been a time in your life that you've been angry with God?
Yes
No
Please explain why you were angry with God.
Have you ever had a fear of losing your mind?
Yes
No
When and why di you have this fear?
Have you had anxiety or panic attacks?
Yes
No
When did this anxiety/panic begin?
Feel incredible loneliness?
Yes
No
Plagued with doubt/unbelief?
Yes
No
Do you feel inferior?
Yes
No
Have thoughts of inadequacy?
Yes
No
Have obsessive thoughts?
Yes
No
Blasphemous thoughts?
Yes
No
Compulsive thoughts?
Yes
No
Sexual dreams?
Yes
No
Lustful thoughts?
Yes
No
Daydream?
Yes
No
Diagnosed with depressions?
Yes
No
Feel the need to be in control?
Yes
No
Rebellious?
Yes
No
On an insecurity scale of 1 - 10, with 10 being the worst, which applies to you?
Female
Check all that apply to you:
Pre-menopausal
In menopause
Post menopause
PMS difficulties
Use or have used birth control pills
Diet or weight control pills
Hormone Replacement Drugs
Below are a few very common symptoms for those under demonic attack. (It doesn't necessarily indicate demonic oppression.)
Check all that apply:
Compulsive desire to blaspheme God.
A revulsion against the Bible, including a desire to tear it up or destroy it.
Compulsive thoughts of suicide or murder.
Feelings of bitterness or hatred toward others without reason. (Jews, other races, the church, Christian leaders...)
Any compulsive temptations which seek to force you to thoughts or behavior which you truly do not want to do/ think.
Compulsive desires to tear other people down, even if it means lying to do so. Vicious cutting by the tongue.
Terrifying feelings of guilt even after honest confession is made to the Lord.
Deep depression and despondency.
Sudden surges of violent range, uncontrollable anger, or seething feelings of hostility.
Terrifying doubt of your salvation even though you once knew the joy of salvation.
Seizures of panic or other fear that is terrifying.
Dreams or nightmares that are of a horrific nature and often recurring. (Clairvoyant dreams that may even come true are most often demonic.)
Abnormal or perverted sexual desires.
Questions and challenges to God's Word.
Sleep or eating disorders without physical cause.
Most compulsions and obsessions. Rebellion and hatred for authority.
Bizarre terrifying thoughts that seem to come from nowhere and you can't control them. Fascination with the occult.
Involvement in criminal activity.
Extremely low self-image (unworthy, a failure, no good - a constant undermining of the identity.)
Constant confusion in thinking.
Inability to believe.
Mocking and blasphemous thoughts against preaching or teaching of the Word of God.
Perceptual distortions (perceiving anger/hostility in others when it doesn't really exist seeings only judgment in scripture)
Nightmares (often having demonic images)
Violent thoughts (suicidal, homicidal, encouraging self-abuse, etc.)
Hatred and bitterness towards others for no justifiable reason.
Fear with encountering one involved in deliverance work.
Deep depression and despondency (frequently & timely)
Irrational fears/panic attacks/phobias
Irrational anger/rage
Irrational guilt. Self-condemnation to the extreme.
Desire to do what is right, but inability to carry it out.
Sudden personality ad attitude changes (sever contrasts - appear schizophrenic)
A strong aversion toward scripture reading and prayer (especially one on one)
A dark countenance (steely or hollow look in eyes, contraction of the pupils, sometimes facial features contort or change - often an inability to look directly at someone)
Lying, exaggerating or stealing compulsively (often wondering why)
Drug abuse (especially when there is demonic hallucinations)
Eating obsessions, bulimia and anorexia nervosa.
Blood transfusion
Irrational laughter or crying
Irrational violence, compulsion to hurt self and/or someone else
Speaking of a language not previously known (often an ethnic language or ancestors)
Reactions to the name and blood of Jesus Christ (verbally or through body language)
Extreme restlessness (especially in a spiritual environment)
Uncontrollable cutting
Vulgar language and actions and mocking of the tongue
Loss of time (from minutes to hours, ending up someplace and not knowing how you got there, regularly doing things of which there is no memory)
Extreme sleepiness around spiritual things
Demonstration of extraordinary abilities (either ESP or Telekinesis)
Voices are heard in the mind that mock, intimidate, accuse, threaten or bargain
Voice speaking from subject - refers to him/her in the third person
Supernatural experiences hauntings, movement or disappearance of objects, and other strange manifestations
Seizures (too long and/or too regular
Pain (without justifiable explanation, especially in head and/or stomach)
Blackouts
Physical ailments (ie.e. epileptic seizure, asthma attacks, various pains)
Sudden (temporary) interference with bodily functions (i.e. bussing in ears, inability to speak or hear, sudden sever headache, hypersensitivity in hearing or touch, sudden chills or overwhelming heat in body, numbness in arms or legs, temporary paralysis
Certain physical symptoms which may appear suddenly or leave quickly, and there are no physical or physiological reason.
Choking sensations
Pains which seem to move around, for which there is no medical cause.
Feelings of tightness about the head or eyes.
Dizziness, blackouts, fainting or seizures.
Any additional comments:
Before submitting this form:
n order for this ministry to be successful, there can be NO unforgiveness in your life. Unforgiveness is legal permission for demons to torment believers. (Matthew 18:23-25) Do not neglect the area of forgiveness for yourself. You must also forgive yourself in order to be free. A typical prayer might be as follows:
"Father, because You have forgiven me, I choose to forgive others, everyone who has hurt me, lied to me or disappointed me, I forgive. I confess unforgiveness as a sin and repent of it. I receive Your forgiveness and apply it to my life by forgiving myself. Thank You for Your grace and mercy in Jesus' name. Amen."
If there was ever any involvement (however innocent) in Satanic activities, witchcraft, cults or occultic activities, they must be renounced. Typical prayer:
"Father, I renounce any bond or agreement I ever made with Satan and the kingdom of darkness. I know there can be no valid contract with a liar and I renounce any words, oaths or pledges made to Satan and I choose to be totally free from the. I choose to be cleansed from any ties with Satan in Jesus' name. Amen."
Sexual relationships outside of marriage... are called "Soul Ties" and each one could be an entry point for demon spirits. The ties must be broken by confessing them as sin and choosing to be free from them. Below is a prayer you can pray. It would be best if you could do so by denouncing each one by name, do the best you can with that. The deliverance process involves canceling permission of evil spirits to be in our life. This prayer and renunciation will cancel consent that was granted through soul ties. The prayer can be something like this: "Father, I confess the sin of sexual relations outside of marriage. I renounce that sinful activity in Jesus' name. I call back that part of me that was given to another, and I refuse that part of another that may have come to me. I denounce soul ties with and choose to be free in Jesus Christ's name. Amen."
False religions must also be confess and renounced:
"Father, because of my relationship to You through Your Son Jesus Christ, and in His Name I renounce all associations with pagan worhsip, false gods, false deities, and any involvement with them. I forgive my ancestors for thier involvement and break any ties to any religion that denies the deity of the Lord Jesus. He alone is Lord. H alone can forgive sin and give man eternal life. I fully trust Jesus Christ and I separate myself from the sins of my ancestors in Jesus Christ's name. Amen."
I have dealt with the above issues and prayed the above prayers.
Yes
No
After submitting this Freedom Ministry Application, someone from the Freedom Ministry will contact you to schedule your ministry session.
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