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    The following questionnaire can be filled out in order to receive a personalized deliverance prayer to deal with your spiritual issues.  Additional questions will most likely be asked via e-mail and discernment/prayer will be used to determine direction in the deliverance process.

CONFESSION OF FAITH

"And they overcame him because of the blood of the Lamb and because of the word of their testimony, and they did not love their life even to death"

"I hereby make a positive confession, that I am a Child of God, that I believe in God the Father, Creator of heaven and earth, and in Jesus Christ His only begotten son, who was conceived by the Holy Ghost, and born of the virgin Mary. I believe that He was crucified for the remission of all sin, died and was buried, went down into hell and rose again on the third day, ascending to heaven to sit at the right hand of God. I believe in the Holy Spirit who was sent by Christ to indwell and fill us who believe."

RENUNCIATION OF THE WORLD, THE FLESH

AND THE DEVIL

"I hereby make a positive confession, that I am a child of God, and am a member or the kingdom of light. As such I renounce the devil and all his works, the vain pomp and glory of the world, with all covetous desires of the same, and the carnal desires of the flesh, so that I will not follow, nor be led by them. I want absolutely nothing to do with the kingdom of darkness, and desire to walk only in the light."

                                                                  Name 

                                                                  Spouse

                                                                  E-mail

                                                                  Date   

*Have you read  the "Confession of Faith" and the "Renunciation of the World, the Flesh, and the Devil and filled in your name and date?
Yes No

1. Have you ever had any traumatic experiences?
Yes No If so please describe the situations and what the emotional consequences have been.

2. Has there ever been any person who has deeply hurt you emotionally or physically?
Yes No If so please describe the situations and who was involved briefly.

3. Are there still people whom you have been unable to forgive for things that were done to you or to others?
Yes No If so describe who and why.

*Please take these people before the Lord and work through the section of forgiveness in War & Freedom (or the Workbook Edition).
4. Are there any emotional problems which are bothering you or others?
Yes No Comments:

5. Check off any of the following which present a problem or a struggle for you:
AngerConfusion ConflictDestruction
DefeatDespair DeceitDiscouragement
Disobedience Fear RejectionHatred
Hostility Destruction Sorrow
Indecision Jealousy Judgmental Mockery
Nervousness Resentment Repression Denial
Laziness Terror Torment Withdrawal
Violence Weariness Despondency Bitterness
Possessive Conceit Indulgence Disinterest
DissatisfactionAnxiety Superstition
Cruelty Fantasy Escape Gloom
CondescendingSkepticism Wastefulness Arrogance
Controlling Fighting Inferiority Argumentative
Unreality Passivity Disgust Tension
Heartache Dread Embarrassment
Suspicion Disinterest Dominance Stubbornness
Spite Loneliness Indifference Suicide
Worry Sensitive Greed Restlessness Defeat
Pride Paranoia Rebellion Weariness
Timidity 
6. Please check off any of the following habits that you may have:
Lying Swearing Blasphemy Gluttony
Lust Stealing Alcohol Abuse Gossip
Fear Drug AbuseBackbiting
Outbursts of Anger Course Jesting
Comments:

7. Check off any involvement with any of the following sexual activities:  Fornication Adultery Incest
Sodomy Lesbianism Excess Masturbation
Bestiality Homosexuality Addiction to Pornography
Please write down the first names of everyone you have had sexual intercourse with:

* If there are names of those whom you cannot remember, or situations in which you are not sure about write at the bottom of the form, "And all others with whom I have had one-flesh unions with."
8. Check off any involvement with any of the following cults or false religions, either actively or passively:
New Age Jehovah Witness
Unification Church Herbert W. Armstrong
Christian Science Rosicrucianism
Zen Buddhism Theosophical Society
Martial arts religions
Father Divine Inner Peace Movt.
Trans. Meditation
Black Muslim Mormonism
Children of God The Way International
Swedenborgianism Unitarianism
Hare Krishna Silva Mind Control
Science of the Mind Roy Masters
Bahaism 
Gurdjieff Masons
Scientology Unity
BuddhismChurch of the Living God
EchkankarMuslim Islam
Yoga Hinduism
Meher Baba Other
Comments:

9. Have you had any history of drug abuse?
Yes No
Comments:

Are you currently on a drug program? YesNo
Please explain giving details on the drugs involved:

10. Please mark any occult activities that you have had an active involvement with :
Fortune telling séance ouija board crystal ball
psychic readings automatic writing clairvoyants charms
occult literature pagan rituals meditations temple ceremonies
blood pacts incantations astrology necromancy
entrail studies materialization occult hypnotism succubae
palm reading life reading Dungeons and Dragons
Tarot cardsLevitation psychic healing amulets
potions Occult rituals Mesmerism
spirit guides voodoo covenants oaths
sorcery consulting the deadBloody Mary astral traveling
fetishism horoscope tea leave reading Planchette
Kaballa pendulum trances talisman
divination magic curses witchcraft
hexes sacrifices vexations wizardry
numerology spells evil eye incubi other
Comments:

11. Have you had any significant spiritual experiences that were positive?
Yes No
Please give details:

Have you had any spiritual experiences that you believe to have been negative?
Yes No
Please explain:

12. Please review chapter 3 of War & Freedom - manual or chapter 2 of War & Freedom - workbook and write down any sinful activity, active or passive, that has not been included in any of the above:

13. Are there any curses that have been placed upon you that you know about?
Yes No
Ask the Holy Spirit to bring to mind any names of those who may have cursed you by their words and write them down (even if you do not understand why there could have been a curse):

Also write down the following:

Any witch doctors/shamans etc. which you may have encountered while on mission trips etc.:

People with whom you have had conflict in business (associates) school, the church etc.:

Names of all pastors and church leaders from any churches you have left in unpleasant circumstances

Names of all ex-girlfriends/boyfriends: (also includes all names from question 6)

Ask the Holy Spirit to reveal to you any objects in your possession that may have been cursed:

14. Family Conflict / Cursing: Please write down the names of all immediate family members including step relatives, and ex-relatives:

Parents:

Grandparents:

Aunts:

Uncles:

Great Aunts:

Grant Uncles:

In-laws:

Outlaws (just kidding):

Ex-spouses:

Partners and ex-partners of all spouses and ex-spouses:

Adoptive parents

Foster parents


15. Are there any specific things which you suffer guilt over on an ongoing basis?
Yes No
If yes, please give details:

16. Are there any specific doctrines of the church that you have a struggle with?
Yes No
Please give details:

17. Do you have any particular physical ailments for which you would like healing:
Yes No
Please give details and instances in which you have had formal prayer:

 *Please read over the following prayer out loud and then type your name and date signifying that you agree with all that is written there:

PRAYER

"Father I bring all the above problems and sins before you and ask that you would cleanse me of all those things that would stand between myself and You. For those that I know to be sin, Lord, I confess these to you, and turn away from them now. I renounce my involvement with them now, in the power and authority of the Lord Jesus Christ. Amen!"

"Father for any oaths, pacts, covenants or commitments that I have made to or with the kingdom of darkness, I confess these to you. I renounce these in the power and authority of the Lord Jesus Christ, and command that they all be broken. I proclaim that they no longer have a hold on me any more in Jesus name. Amen!"

"Father for any spells, curses, incantations, hexes, vexes, magic, sorcery, voodoo, charms, potions, or other forms of witchcraft that I have been involved with, I break all of these in the power and authority of the Lord Jesus Christ. Anything from the kingdom of darkness that I have sent or given to other people I renounce, and loose from them, in the power and authority of the Lord Jesus Christ. Anything that I have received from the kingdom of darkness, I renounce and reject, in the name of Jesus. Amen!"

"Father I ask that you would release me from any one-flesh unions that are not from you. I confess these now to you and renounce them in the power and authority of the Lord Jesus Christ. Please cleanse me from these now, in Jesus name. Amen!"

"Father right now I ask you for your grace. I right now forgive all those with whom I have withheld forgiveness. Please fill me with Your love and concern for these people, in Jesus name. Amen!"

"Father I ask right now that if there have been any demons that have been released by any of the above prayers and commands, that you would send angels to encircle them and lead them away to where Jesus Christ would send them. I ask as your child that you would do this for me, in Jesus Name. Amen!"

"Father I ask that you would send your Spirit as a refining fire to cleanse all the areas of my life that are being vacated by the kingdom of darkness, and that you would fill me with yourself. I ask all this in the name of Jesus Christ my Lord. Amen!"

                                                         Name 

                                                         Date   

 

 


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Revised: April 02, 2003
 

 

 

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