Desert Deliverance 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 *

Are you familiar with Zoom video conferencing?

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How did you hear about us? (i.e. a friend, Google, Bing, Chatgpt, etc.) *
If you found us on a search engine, what exactly were you searching for when you found us?
How familiar are you with deliverance ministry? Have you watched any videos? If yes, who's videos? (example answer: not very, a few, random) *
Have you received deliverance prayer before? If yes, how many times? Did you feel free? (example answer: Yes, 3 times, no) *
Are you currently attending church services on a regular basis? If no, please explain. *
If yes, what denomination (or non-denominational)? *

Have you had any of the following? Please select all that apply.

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Describe briefly the issues you are struggling with that have brought you here today? *

What would you like to focus on during your time with us? (check all that apply)

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If you answered "Other" in the above question, please explain.
Are you currently under the care of a mental health professional? (i.e. Psychiatrist, Behavior Health Counselor, etc.) If yes, please explain. *
If you answered yes to the above question, list names of any disorders you are being prescribed medication for.

Please select the option that best applies to you.

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Please select the option that best applies to you.

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Choose A, or B

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Any additional comments? (optional)