Intake Form Please complete this history form to prepare the team for their session with you. All information is strictly confidential. "*" indicates required fields Step 1 of 5 - Your Information 20% Thank you for inviting us to come alongside you on your freedom path. We are blessed and honored to partner with you!Please take some set-aside time with the Holy Spirit to answer the questions on this intake form. Let Him lead and direct you in your answers. This is a helpful tool for you and for us, and we trust the Lord in this process. If you have any questions, please call your pastor. (Note: this is not any sort of a test, and it is completely confidential.) We will look to get a time scheduled on the calendar once we have this returned.Please complete this history form to prepare the team for their session with you. Write “N/A” (Not Applicable) in any area that does not apply to you. All information that you provide is strictly confidential and will be viewed only by the individuals involved in personal ministry with you.Our services are free of charge, but we do accept and appreciate love offerings based upon what God is putting on your heart.In Christ,Shane and Heather — Double Pourtion MinistriesYour InformationToday's Date* MM slash DD slash YYYY Your Name* Spouse's Name Your Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country PhoneEmail Prior Marriages? Yes No If so, how many?Names of ChildrenDate of Birth MM slash DD slash YYYY Were you the first born? Yes No Are you a Born-Again Christian? Yes No If so, where and at approximately what age? Best Time To Meet Week Days Week Nights Week Ends Family & Personal HistoryThe purpose of this section is to help determine possible entryways for evil spirits. Generational/ancestral permission (Exodus 20:5) is a possibility in anyone's life. Please give any information that the Holy Spirit brings to your mind. It is not necessary to go into great detail — ask the Holy Spirit to show you any area of concern.1.) Are you aware of ancestor involvement in any of these: the occult, sexual perversion, alcoholism, depression or mental disorders, lots of divorce, adultery, anger, criminal activity, births out of wedlock, or groups such as Free Masons, Eastern Star, Rainbow Girls, Oddfellows, Rebecca Lodge, etc.? Yes No If Yes, please explain:2.) From birth and early childhood: Are you aware of any trauma you might have experienced during your mother's pregnancy? (Accidents, divorce, spoken words such as "We shouldn't be having this child," etc.)3.) Do you recall any early childhood fears, injuries, or nightmares? Do you remember seeing things in your room or feeling an evil presence? Do you recall any encounters of a supernatural kind?4.) Any sexual abuse, or sexual embarrassment through childhood?5.) Do you recall any spoken words of condemnation from parents or others ("You're fat, you're stupid, you'll never amount to anything," etc.)? Any embarrassing or humiliating experiences at school or from a teacher or coach?6.) Any physical abuse from parents or others?7.) Involvement (however innocently) with Ouija boards, Magic 8 Ball, levitation games, seances, fortune tellers, tarot cards, astrology, horoscopes, books about magic, psychic seers, Harry Potter books, Pokemon cards, etc.?8.) Please list accidents or injuries that come to mind as being frightening to you at the time:9.) Please list surgeries and approximate age:10.) Movies or TV programs that were particularly frightening to you, or specific scenes that stick in your memory:11.) Have you participated in pre-marital sex? Yes No 12.) Periods of, or habitual, immorality? (including pornography, sexual fantasy, promiscuity, etc.)13.) Drinking and/or drug use?14.) Do you experience unusual fears?15.) What do you think may be the areas of demonic influence in your life?16.) Are (or were) there any significant problems in the home?17.) Are your parents divorced? Yes No If Yes, how old were you? 18.) Unusual feelings such as: never really felt loved, couldn't please my father/mother, feelings of worthlessness, etc.?19.) Have you been exposed to pornography? Yes No If Yes, how old were you? Please answer the following questions as they apply to your life:20.) Homosexual tendencies? Yes No 21.) Participated in college fraternities or sororities? Yes No 22.) Feelings of guilt and shame? Yes No 23.) Hopelessness? Yes No 24.) Fatigue without medical reason? Yes No 25.) Have you had an abortion? Yes No 26.) Difficulty in forgiving? Yes No 27.) Do you have bitterness, anger, or unforgiveness? Yes No 28.) If so, can you forgive? Yes No 29.) Do you experience feelings of self-hate? Yes No 30.) Have you suffered from self harm? Yes No 31.) Do you have feelings of gloom? Yes No 32.) Do you feel rejected? Yes No 33.) Do you have any objects in your home or possession that relate to ungodliness or cults? (New age items, books about eastern deities, crystals, heavy metal music, Native American/African artifacts, items connected with other religions or rituals, Wiccan or other occult items, etc.) Yes No If Yes, please identify or explain:34a.) Have you ever "felt" a presence in the room? Yes No 34b.) If Yes, has it been recently? Yes No If either question was Yes, please explain:35a.) Do you have nightmares? Yes No 35b.) Do you hear voices? Yes No If either question was Yes, please give an example:36.) Have you been diagnosed by a doctor as having (e.g., diabetes, asthma, hypertension, bi-polar, ADD, ADHD, autism, etc.)? Yes No If Yes, list the diagnosis here:37.) Do you have inexplicable pain... no medical explanation for it? Yes No If Yes, please explain:38.) Do you have difficulty in trusting others? Yes No If Yes, do you know why? Please explain:39.) Has there been a death of someone close to you? Yes No If so, whom? 40.) Do you feel like you have any eating disorders? Yes No If Yes, do you know when they began?Approximate height: Approximate weight: 41.) Do you suffer from sleep disorders? Yes No 42.) Any other medically defined disorder? Yes No If Yes, please explain:43.) Is there a history of tuberculosis, diabetes, ulcers, cancer, heart disease, glandular problems, asthma, or other illness in your family? Yes No If Yes, please explain:44.) Did you have imaginary friends as a child? Yes No If Yes, what were their names?45.) When attending church or other ministries, do you have "foul" thoughts, jealousies, or other mental harassment? Yes No 46.) Do you have difficulty retaining God's Word? Yes No 47.) Difficulty in reading it? Yes No 48.) Do you have migraine headaches? Yes No 49.) Do you have any addictions? Yes No 50.) Were you ever diagnosed with a learning disability, i.e. (ADD), etc.? Yes No 51.) Do you have a fear of death? Yes No 52.) Have you ever had suicidal thoughts? Yes No 53.) Has there been a period of time in your life when you were angry with God? Yes No 54.) Do you have a fear of losing your mind? Yes No 55.) Do you suffer from anxiety or panic attacks? Yes No If Yes, when and how did they begin?56.) Do you feel incredible loneliness? Yes No 57.) Are you plagued with doubt and unbelief? Yes No 58.) Do you feel inferior? Yes No 59.) Do you have thoughts of inadequacy? Yes No 60.) Do you have obsessive thoughts? Yes No 61.) Blasphemous thoughts? Yes No 62.) Compulsive thoughts? Yes No 63.) Lustful thoughts? Yes No 64.) Do you daydream? Yes No 65.) Are you a perfectionist? Yes No 66.) Are things seemingly always out of order? Yes No 67.) Do you feel the need to be in control? Yes No 68.) Are you rebellious? Yes No A Few More Questions69.) Feelings of Insecurity? (On a scale of 1-10, with 10 being worst) 1 2 3 4 5 6 7 8 9 10 Please briefly explain your response:70.) Here are a few symptoms of demonic attack. Please check any symptom that applies to you: A 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 Deep feelings of bitterness and hatred toward others without reason (other races, the church, strong Christian leaders) Any compulsive temptations forcing you to thoughts or behavior you truly do not want Compulsive desires to tear other people down, even by lying; vicious cutting down of others by the tongue Terrifying feelings of guilt even after honest confession is made to the Lord Physical symptoms that appear suddenly or leave quickly with no physical/physiological reason Choking sensations Pains that seem to move around and for which there is no medical cause Feelings of tightness about the head or eyes Dizziness, blackouts, or fainting seizures Deep depression and despondency Sudden surges of violent rage, uncontrollable anger, or seething hostility Terrifying doubt of one's salvation even though you once knew the joy of salvation Seizures of panic or other terrifying fear Dreams or nightmares of a horrific, often recurring nature; clairvoyant dreams 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 cannot control Fascination with the occult Involvement in criminal activity Extremely low self-image (unworthy, a failure, no good) Constant confusion in thinking (difficulty remembering things) Inability to believe (even when you want to) Mocking and blasphemous thoughts against preaching/teaching of the Word of God Perceptual distortions (perceiving anger/hostility that isn't there; seeing only judgment in scripture) Horrible nightmares causing fear (often having demonic images) Violent thoughts (suicidal, homicidal, encouraging self-abuse) Hatred and bitterness toward others for no justifiable reason Tremendous hostility or fear when encountering someone involved in deliverance work Feelings of being watched or sensing an evil presence Deep depression and despondency (frequently and at significant times) Irrational fears, panic attacks, phobias Irrational anger, rage Irrational guilt, self-condemnation to the extreme Desire to do what is right (inability to carry it out) Sudden personality and attitude changes (appears schizophrenic / bi-polar) A strong aversion toward scripture reading and prayer (especially one-on-one) A dark countenance (steely or hollow look in eyes, pupil contraction, inability to look at others directly) Lying, exaggerating, or stealing compulsively (often wondering why) Drug abuse (especially with demonic hallucinations) Eating obsessions (bulimia, anorexia nervosa) Compulsive sexual sins (especially perversions) Irrational laughter or crying Irrational violence, compulsion to hurt self and/or someone else Sudden speaking of a language not previously known Reactions to the name and blood of Jesus Christ Extreme restlessness (especially in a spiritual environment) Uncontrollable cutting and mocking tongue Vulgar language and actions Loss of time (ending up someplace not knowing how, doing things with no memory) Extreme sleepiness around spiritual things Demonstration of extraordinary abilities (ESP or telekinesis) Voices heard in the mind (mock, intimidate, accuse, threaten, or bargain) Voice refers to him/her in the third person Supernatural experiences (hauntings, movement or disappearance of objects, strange manifestations) Seizures (too long and/or too regular) Pain without justifiable explanation (especially head and/or stomach) Blackouts Physical ailments alleviated immediately by a command of spiritual authority Sudden temporary interference with bodily functions (buzzing in ears, inability to speak/hear, sudden headache, chills or heat, numbness, temporary paralysis) Note: A few symptoms may not indicate demonic oppression, but these are very common symptoms for those under demonic attack.Additional Comments: Before Coming For DeliveranceYou can get started now with your freedom. We recommend that you spend time with the Holy Spirit and deal with these issues before coming for deliverance.In order for the deliverance to be successful there can be NO unforgiveness in your life. Unforgiveness is legal permission for demons to torment believers (Matthew 18:23). Do not neglect the area of forgiveness for yourself — you must also forgive yourself in order to be free. A typical prayer might be:“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 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 occult activities, they must be renounced. A 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 them. 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. A 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 them and choose to be free in Jesus Christ's Name. Amen.”Liability Release & AcknowledgmentLiability Release*I hereby acknowledge and affirm that all answers given by myself in response to the questions in this form are voluntarily submitted and that the information is true to the best of my knowledge. I hereby release, indemnify, and forever hold harmless Double Pourtion Ministries / Rising Fire Ministries and their agents and volunteers of any damages, real or perceptual, arising from personal ministry in connection with the information submitted herein. Note: This is a free service. Donations are gladly accepted based on what God puts on your heart. I acknowledge and agree to the statement above.Name (Please print)* Name of Parent or Legal Guardian (required if person filling out the form is under 18): Signature (type your full legal name)* By typing your name you are signing this form electronically.Date* MM slash DD slash YYYY Are you regularly involved with a local fellowship of believers? (e.g., home church, small group, etc.)EmailThis field is for validation purposes and should be left unchanged.
