Forms

Personal Information

Name *

Marital Status *MarriedSingelDivorced

Number of Children *

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Phone *

Email Address *

Date of Birth *

Month

Day

Year

• How long have you been a Born Again Christian? *

Parents’ History

Have you experienced any of the following?

Check all that apply *Trauma during your mother’s pregnancy (e.g., accidents, divorce, negative words, alcoholism/drugs)Early childhood fears, injuries, nightmares, or supernatural encountersSexual abuse or embarrassment during childhoodPhysical abuse from parents or othersCondemning or humiliating words from parents, teachers, or othersInvolvement with witchcraft or the occult (e.g., Ouija boards, tarot cards, astrology, magic books, TV shows, Eastern or pagan religions, Christian Science, yoga, karate, cults, Mormonism, Jehovah’s Witnesses, false doctrine, etc.)Pre marital sex or sexual immorality, masturbation, sex machines/toys (e.g., pornography, sexual fantasy, promiscuity)Drinking or drug use; smoking

Include any/all not mentioned:

Have you been diagnosed with any medical conditions (ADD/ADHD, OCD, Tourette’s/tics, Autism Spectrum Disorder)?YesNo

If Yes, please state which condition:

Do you take any prescribed medication?YesNo

Is the medication working?YesNo

How does it make you feel?

Do you have inexplicable pain in your body (that doctors can’t explain)?YesNo

If Yes, when did it start? Please explain:

Do you experience sleep disorders (narcolepsy, cataplexy, insomnia)?YesNo

If Yes, please explain:

Are you a compulsive eater?YesNo

Can you control your eating habits?YesNo

Explain:

Do you fall asleep while reading the Bible or while praying?YesNo

Explain:

Do you have any objects in your home related to witchcraft or cults?Idols or occult itemsBooks about Eastern deitiesCrystals or birthstonesHeavy metal musicNative American/African artifactsWiccan items

Other (please specify):

Has anyone ever given you something they told you to wear and never take off?YesNo

If any, please explain:

Additional CommentsUse this space to provide any other information you feel is necessary for your deliverance session (e.g., when your struggles started, known triggers, when they are magnified, and environments where they occur).

Liability ReleaseI hereby acknowledge and affirm that all answers provided in this form are voluntarily submitted and are true to the best of my knowledge. I release, indemnify, and hold harmless DAS Ministries and its volunteers from any damages arising from personal ministry in connection with the information submitted herein. Our aim is to assist you in evaluating your situation to help you walk in freedom.AgreeDisagree

Expectations & Commitment

Our ministry team commits time to pray, prepare, and meet with you. In return, we ask that you come with a genuine desire to grow and overcome the challenges you’re facing. Please be on time, remain open to what God is doing, and follow through with any assignments or steps given. Your full engagement will help you receive the most from your ministry time.

If you book a session and are unable to attend, please provide at least 48 hours’ notice. Repeated no‑shows or cancellations affect others. If you miss or cancel two sessions without notice, we will not re‑book future sessions (except in emergencies).

Name (Please Print)

Date

Month

Day

Year

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