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?

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If you found us on a search engine, what search phrase were you using 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/worship 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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What specific symptoms are you experiencing that cause you to believe you are need of ministry? (your primary areas of struggle) *

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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Please click on "Testimonials" at the top of this page and read what others have said about their experiences with us before answering this question. We are staffed by volunteers. Your donations help them make ends meet. Choose A, or B from the choices below.

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Any additional comments? (optional)