Intake Form

Please fill in the blanks or check the boxes for any items that apply to you, then click the SUBMIT button when finished.

(Red asterisk ✳ indicates required response)

First Name *
Last Name *
E-mail *
Empty *	I am familiar with Zoom video conferencing. I am not familair with Zoom video conferencing.
How did you hear about Desert Deliverance? *
How familiar are you with deliverance ministry? Watched any videos? Who's? *
Are you currently attending church services on a regular basis? *
If yes, what denomination? *
Have you had any of the following? Please select all that apply. *	a water baptism a born again experience a baptism in the Holy Spirit None of these apply to me
Do you have a relationship with mature Christian friends, or a small group that can help you continue to grow after receiving ministry? *	Yes No
Have you received deliverance prayer before? If yes, did you feel free? *
Briefly, what is going on in your life that has brought you here today? *
Are you involved in ongoing secular (non-religious) counseling or therapy? If yes, please explain. *
Are you currently receiving ministry from a healing/deliverance minister, or your pastor? *	Yes No
	I am 12 years old or younger. (Checking this box will not disqualify you from receiving ministry.)
Please select the option that best applies to you. *	I understand that in order to retain my deliverance it will be necessary for me to avoid behaviors that caused me to need deliverance in the first place, and I am prepared to do that. I am just looking for a quick fix to relieve my suffering. My current sinful life suits me just fine.
Please add any additional comments that you feel may be helpful.