Freedom • Healing • Restoration

BLOODLINE

DELIVERANCE

Please complete the form below carefully and honestly. All information submitted will remain confidential.

🟢 SECTION 1: BASIC INFORMATION

Full Name *

Email *

Phone *

Age *

Address

Street Address *

Country *

Enter your country

State *

City *

Postal Code *

Marital Status *

🟣 SECTION 2: SPIRITUAL FOUNDATION

Do you consider yourself a Christian? *

Yes

No

Unsure

How would you describe your current relationship with God? *

Strong

Growing

Struggling

Distant

What are you currently seeking freedom or breakthrough from? *

🔵 SECTION 3: CURRENT SYMPTOMS & STRUGGLES

Current Symptoms & Struggles *

Anxiety or Panic

Depression

Fear

Intrusive Thoughts

Confusion / Lack of Clarity

Mood Swings

Nightmares

Suicidal Thoughts

Anger or Rage

Bitterness or Unforgiveness

Addiction

Sexual Struggles

Compulsive Behaviors

Self-sabotage

Difficulty Praying

Feeling Distant from God

Blasphemous Thoughts

Spiritual Resistance

Feeling Spiritually Oppressed

🟣 SECTION 3A: SELF-ASSESSMENT

Do you believe you are currently experiencing demonic influence or oppression? *

Yes

No

Unsure

If yes or unsure, explain why: *

🔴 SECTION 4: FAMILY & BLOODLINE HISTORY

Family & Bloodline History *

Addiction

Divorce

Abuse

Poverty

Mental illness

Chronic sickness

Occult involvement

Violence

Describe any repeating patterns in your family: *

Any known involvement in the following in your family line: *

Witchcraft

Secret Societies

Non-Christian Religions

Generational Trauma

🟠 SECTION 5: TRAUMA HISTORY

Trauma History *

Physical Abuse

Emotional Abuse

Sexual Abuse

Neglect

Major Accidents

Loss / Grief

Abandonment

Describe significant life events that impacted you: *

🟡 SECTION 6: OCCULT & SPIRITUAL EXPOSURE

Occult & Spiritual Exposure *

Ouija Board

Tarot / Divination

Astrology

Psychic Readings

Witchcraft

Energy Healing

Yoga (Spiritual Context)

Spirit Guides

Voodoo / Santeria

Explain any involvement: *

🟤 SECTION 7: ADDICTIONS & HABITS

Addiction & Habits *

Alcohol

Drugs

Pornography

Food Issues

Gambling

Spending Habits

⚫ SECTION 8: SEXUAL HISTORY (CONSENT-BASED)

Sexual History (Consent-Based) *

Sexual Trauma

Pornography

Promiscuity

Adultery

Same-Sex Encounters

Sexual Confusion

Additional details:

⚪ SECTION 9: HEALTH & MEDICATIONS

Any diagnosed medical or mental health conditions:

Current Medications:

🔵 SECTION 10: DEMONIC ACTIVITY INDICATORS

Demonic Activity Indicators *

Hearing Voices or Intrusive Thoughts

Feeling a Presence

Sleep Paralysis

Loss of Control

Mood / Personality Shifts

Resistance during Prayer

Night Attacks

Seeing Shadows or Figures

🟣 SECTION 11: AGREEMENTS / OPEN DOORS

Have you ever made any vows, agreements, or participated in rituals? Explain:

🟢 SECTION 12: FORGIVENESS

Is there anyone you are struggling to forgive? *

🔴 SECTION 13: EXPECTATION & READINESS

Why are you seeking this session now? *

Are you willing to: *

Forgive Others

Renounce Past Agreements

Actively Participate

Are you willing to: (Choices) *

Yes

No

Unsure

🟡 SECTION 14: FINAL COMMENTS

Anything else you would like to share before your session:

Next

BLOODLINE

DELIVERANCE

This site provides faith-based ministry services only and does not offer medical or licensed counseling advice. No outcomes are guaranteed.

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