Support Name First Last Email PhoneDate of birthAre you Married? Yes No Spouse's NamePrior Marriage? Yes No If so, how many?Name and ages of childrenAre you the first born child?Are you a born again Christian?How long have you been saved?Are you Spirit Filled with a prayer language?The purpose of this questionnaire is to help determine possible entryways for evil spirits. There are 30 ancestors in your history that could have passed on generational line strongholds. Please give any information that the Holy Spirit brings to your attention: Examples would be involvement with the occult, sexual perversion, alcoholism, depression or mental disorders, lots of divorce, adultery, anger, criminal activity, births out of wedlock, involvement in groups such as Masonry, Eastern Star, Rainbow Girls, Oddfellows and Rebecca Lodge etc Yes No If yes, please explainNote: It is not necessary to go into great detail with any of the responses. Ask Holy Spirit to show you any area of concern.From birth or early childhood: Are you aware of any trauma you might have experienced while your mother was pregnant with you? Please list any accidents, divorce, spoken words such as "We shouldn't be having this child" etc.? Please explainDo you recall any early childhood fears, injuries, nightmares? Do you remember seeing things in your room or feeling an evil presence? Do you recall any encounters of a supernatural kind?Was there any sexual abuse or sexual embarrassment in childhood?Do you recall any spoken words from parents, or others that were condemnation: "You're fat, you're stupid, you'll never amount to anything, you always mess up, I don't know why we had you. You can't be in our group, etc embarrassing or humiliating experiences at school or from teachers?Has there been any physical abuse from parents or others?Please list any surgeries you've had even as a childHas there been any involvement in Ouija boards, Magic 8 Ball, levitation games, seances, fortune tellers, tarot cards, astrology, horoscopes, fascination with books about magic, physics seers, Harry Potter books, Pokemon cards, etc.?Any accidents or injuries that have caused you fear?Were there any movies or TV programs that were particularly frightening to you, or specific scenes that seem to stick in your memory?Have you participated in premarital sex? Yes No Have there been periods of, or habitual immorality? (including pornography, sexual fantasy, promiscuity, etc.)Have you engaged in drinking and/or drug use?Do you experience unusual fears?What do you think may be the areas of demonic influence in your life?Are there or have there been any significant problems in the home?Are your parent's divorced? Yes No Do you have feelings of never really felt loved, couldn't please my father/mother, feelings of worthlessness, etc.?Please explainHave you been exposed to pornography? If Yes, how old were you? _______ Yes No Please answer the following questions as they apply to your life: ( Yes or No)Do you have Homosexual tendencies? Yes No Have you participated in college fraternities or sororities? Yes No Do you have feelings of guilt and shame? Yes No Do you experience feelings of hopelessness or dispair? Yes No Do you experience feelings of fatigue without medical reason? Yes No Have you had an Abortion? Yes No Do you have difficulty forgiving? Yes No Do you have bitterness, anger, or unforgiveness? Yes No Do you experience feelings of self hate? Yes No Have you suffered from self harm? Yes No Do you experience feelings of rejection? Yes No Are there any objects in your home or in your possession that relate to ungodliness or cults, this would include new age religions, such as books about eastern deities, crystals, heavy metal music, Native American/African artifacts, Items connected with other religions or rituals, Wiccan or other occult items, etc.? Yes No If yes, please identify and explainHave you ever "felt" a presence in the room home recently? Yes No If yes, please explainDo you hear voices? Yes No Do you have nightmares? Yes No If yes to nightmares or voices please explainHave you been diagnosed by a doctor as having: (list any diagnosis, diabetes, asthma hypertension, etc.)? Yes No If yes to any diagnosis please list below.Do you experience pain in your body with no medical explanation? Yes No If yes, please explainDo you have difficulty trusting others? Yes No If yes, do you know why? Please explainHave you had someone close to you die? Yes No Have you had someone close to you die? Yes No If yes, please list people and relation to youDo you feel like you have any eating disorders? Yes No If yes, what age did this begin? Please list height and weight belowDo you have any sleep disorders Yes No Are there any other medically defined disorders? Please explain belowIs there a history of tuberculosis, diabetes, ulcers, cancer, heart disease, glandular problems, asthma or other in your family? If Yes, please explain belowDid you have an imaginary friend or friends as a child? If yes, please list their names belowWhen attending Church or other ministries do you have "foul" thoughts, jealousies or other mental harassment? Yes No Do you have difficulty retaining God's Word? Yes No Do you have difficulty reading God's Word? Yes No Do you get migraine headaches? Yes No Do you have any addictions? Yes No Have you ever been diagnosed with a learning disability i.e. (A.D.D.)? Yes No Do you have a fear of death? Yes No Have you ever had suicidal thoughts? Yes No Has there been a period of time in your life when you were angry with God? Yes No Do you have a fear of losing your mind? Yes No Do you suffer from anxiety or panic attacks? Yes No If yes, when did the attacks begin?Do you feel incredible loneliness? Yes No Are you plagued with doubt and unbelief? Yes No Do you have feelings of inferiority? Yes No Do you have thoughts of inadequacy? Yes No Do you have obsessive thoughts? Yes No Do you have blasphemous thoughts? Yes No Do you have compulsive thoughts? Yes No Do you daydream? Yes No Do you have lustful thoughts? Yes No Are you a perfectionist? Yes No Are things seemingly always out of order? Yes No Do you feel the need to be in control? Yes No Are you rebellious? Yes No Do you have feelings of insecurity? On a scale of 1-10 ten being the worst. Please write a number and briefly explain your responseBelow are a few symptoms of demonic attack, please check any symptom that applies to you:Untitled Consent(Required) I agree to the liability waiver.I hereby acknowledge and affirm that all answers given by myself in response to the questions in this form are voluntarily submitted and that the information is true to the best of my knowledge. I hereby release, indemnify and forever hold harmless Billy & Bethany Robbins, Abiding Love and its agents, staff, employees and volunteers of any damages, real or perceptual, arising from personal ministry in connection with the information submitted herein.Signature Δ
