Intake Form

Desert Deliverance

Intake Questionnaire

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 us? If you found us on a search engine, what exactly were you searching for? (i.e. online deliverance, deliverance ministry, etc)? *
How familiar are you with deliverance ministry? Have you watched any videos? If yes, who's videos? *
Have you received deliverance prayer before? If yes, how many times? Did you feel free? *
Are you currently attending church services on a regular basis? If no, please explain. *
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
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
Please select the option that best applies to you. *	I am 12 years old or older. I am younger than 12 years old.
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.