Need Help?

I may have a demon. Can you help?

Based on research and experience we have prepared a deliverance form for you to fill out and determine if there are any open entryways for the demonic realm. These are permissions granted either by your willful sinning or generational curses. Unforgiveness is the number one permission satan uses against a believer. Please pray and ask the Holy Spirit to reveal to you places of sin, unforgiveness and possible occult activities.

Fill out the form below for assistance, and we will be in touch!

Name

First

Last

Email *

Date / Time *

Date

Time

Marital Status *

Spouse's Name

Prior Marriages?

How many Marriages

Any Children?

Yes
No
I have step-children

Date of Birth

Were you the First Born

Are you a Born Again Christain?

Yes
No
I am not sure

If Yes, where and what age?

at disability

Best time to meet

Week Days
Week Nights
Week Ends

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. Examples would be involvement with the occult, sexual perversion, alcoholism, depression or mental disorders, lots of divorce, adultery, anger, criminal activity, births out of wedlock, involvement in groups such as Masonry, Eastern Star, Rainbow Girls, Oddfellows and Rebecca Lodge etc.

Are you aware of ancestors involvement in any of these?

If yes, please explain

Note: It is not necessary to go into great detail with any of your responses. Ask the Holy Spirit to show you any area of concern.

From birth and your 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.?

Please explain

Do you recall any early childhood fears, injuries, nightmares? Do you remember seeing things in your room or feeling an evil presence? Do you recall any encounters of a supernatural kind?

Please explain

Any sexual abuse, or sexual embarrassment through childhood?

Please explain

Do you recall any spoken words from parents, or others that were condemnation: "You're fat, you're stupid, you'll never amount to anything, you always mess up, I don't know why we had you. You can't be in our group, etc embarrassing or humiliating experiences at school or from school teacher?

Please explain

Any physical abuse from parents or others

Please explain

Involvement (however innocently it may have been) with Ouija Boards, Magic 8 Ball, levitation games, seances, fortune tellers, tarot cards, astrology, horoscopes, fascination with books about magic, physics seers, Harry Potter books, Pokemon cards, etc.?

Please explain

Please list accidents or injuries that come to your mind as being frightening to you at the time:

Please list surgeries and approximate age

Movies or TV programs that were particularly frightening to you, or specific scenes that seem to stick in your memory:

Have you participated in pre-marital sex?

Periods of, or habitual immorality? (including pornography, sexual fantasy, promiscuity, etc.)

Please explain

Drinking and/or drug use

Do you experience unusual fears?

Please explain

What do you think may be the areas of demonic influence in your life?:

Are (or were) there any significant problems in the home?

Please explain

Are your parents divorced?

If so, how old were you?

Unusual feelings such as: Never really felt loved, couldn't please my father /mother, feelings of worthlessness, etc.?

Have you been exposed to pornography?

If so, how old were you?

Please answer the following questions as they apply to your life:

Homosexual tendencies?

Participated in college fraternities or sororities?

Feelings of guilt and shame?

Hopelessness?

Fatigue without medical reasons?

Have you had an abortion or assisted someone else?

Difficulty in forgiving?

Is there bitterness, anger, or unforgiveness?

If so, can your forgive?

Do you experience feelings of self-hate?

Have you suffered from self harm?

Do you have feelings of gloom?

Do you feel rejected?

Do you have any objects in your home or possession that relate to ungodliness or cults, this would include new age religions, such as 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.?

Please explain

Have you ever "felt" a presence in the room?

If Yes, has it been recently?

If either question was Yes, please explain

Do you have nightmares?

If Yes, do you hear voices?

If either question was Yes, please explain

Have you been diagnosed by a doctor as having: (list any diagnosis, diabetes, asthma hypertension, etc.)?

List any diagnosis here

Do you have inexplicable pain ... no medical explanation for it?

If Yes, please explain

Do you have difficulty trusting others?

If Yes, please explain

Has there been a death of someone close to you?

If so, whom?

Do you feel like you have any eating disorders?

If Yes, explain when they begin?

Please give approximate height and weight

Do you suffer from sleep disorders?

If Yes, please explain

Any other medically defined disorder?

If Yes, please explain

Is there a history of tuberculosis, diabetes, ulcers, cancer, heart disease, glandular problems, asthma, other in your family?

If Yes, please explain

Did you have any imaginary friends as a child?

If Yes, what was their name(s)

When attending Church or other ministries do you have "foul" thoughts, jealousies or other mental harassment?

Do you have difficulty retaining God's word?

Difficulty in Reading Go's word?

Do you have migraine headaches?

Do you have any addictions?

If Yes, please explain

Were you ever diagnosed with a learning disability i.e. (ADD) etc?

Do you have a fear of death?

Have you ever had suicidal thoughts?

Has there been a period of time in your life when you were angry with God?

Do you have a fear of losing your mind?

Do you suffer from anxiety or panic attacks?

If Yes, how did they begin? What age?

Do you feel incredible lonliness?

Are you plagued with doubt and unbelief?

Do you feel inferior?

Do you have thoughts of inadequecy?

Do you have obsessive thoughts?

Blasphemous thoughts?

Compulsive thoughts?

Lustful thoughts?

Do you daydream?

Are you a perfectionist?

Are things seemingly always out of order?

Do you feel the need to be in control?

Are you rebellious?

Check All That Apply

Note: A few symptoms may not indicate demonic oppression...but these are very common symptoms for those under demonic attack.. After all there is really nothing to lose by doing so, except one's pride. When in doubt ... cast them out!

Additional comments

Before Coming For Deliverance:

There is something you can do to help bring about your freedom. I recommend that you 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 18:23-35. 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 sin and repent of it. I receive Your forgiveness and apply it 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.

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. I will include 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 them and choose to be free in Jesus Christ' Name. Amen"

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 Childrens Bread of NC, David & Debbie Deaton and its agents, staff, employees and volunteers of any damages, real or perceptual, arising from personal ministry in connection with the information submitted herein.

I am over 18 years old

Anyone under the age of 18 must be accompanied by a Parent or Guardian

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