• Yes 

• No

If so please write down the incident/incidents and/or names of the people involved.

If so please write down their names, or a description of the incident.

Please write down their names and the incident/incidents.

• excess masturbation

• lust

• fornication

• adultery

• incest

• homosexuality

• lesbianism 

• sodomy

• bestiality 

• addiction to pornography

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:

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

14. Are there any specific things which you suffer guilt over on an ongoing basis?

• Yes

• No 

• Write them down.

15  Are there specific doctrines of the church that you have a struggle with?

• Yes

• No

• Please give details:

16. Do you have any particular physical ailments for which you would like healing? 

• Yes 

• No 

• Please give details:

"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!"

                                                                Signed

                                                                Date