Name * First Name Last Name Phone (###) ### #### Email * Age Martial Status: Married Single Separated Divorced Cultural / Ethnic Background Check the box that describes the relationship with each person as a CHILD Biological Father Good Bad Other Biological Mother Good Bad Other Stepfather Good Bad Stepmother Good Bad Siblings Good Bad Were you a wanted/planned child? Yes No I don't know Were you conceived out of wedlock? Yes No I don't know Were you adopted? Yes No SPIRITUAL EVALUATION Describe your relationship with God: Excellent Could use improvement Poor Salvation/Christian confession Yes No OCCULT PRACTICES If you have participated, please check the box Astral Projection Astrology/horoscopes Automatic writing/painting Channeling Fortune telling Incantations Magic - White/Black Ouija Board Seances Spells Tarot Cards Witchcraft/Wicca NEW AGE PSYCHIC PRACTICES Past-Life Therapy Psychic Consultation Spirit Guides Telepathy Trances Transcendental Meditation Voodoo Yoga RELIGIOUS BELIEFS, CULTS, SECRET SOCIETIES & OTHERS If you or your family have participated in any of these, please check the box Atheism/Agnosticism Buddhism/Zen Church of Satan Hinduism Islam Jehovah's Witnesses Kabbalism Freemasonry Mormonism Neo-Nazis/Skinheads KKK/Racism Reincarnation Santeria Satanism Scientology Voodoo Witchcraft Military Branch Gang Fraternity/Sorority PHYSICAL HEALTH ISSUES Cancer Diabetes Epilepsy Gastrointestinal issues Heart Disease Infertility Other Health Issues MENTAL HEALTH If you or your family members have this mental health issue, please check the box ADD/ADHD Anxiety/Panic Disorder Bipolar Borderline Depression OCD (Obsessive compulsive) MPD/DID (Multiple Personalities) Schizophrenia Phobias Post-Traumatic Stress Disorder EMOTIONAL / BEHAVIORAL HEALTH Please check the box that best describes you Panic Attacks Depressed Fearful Low Self-Esteem Nightmares Self-Condemnation Worthlessness Anger Issues Bitterness Emotional Abuse Frustration Hatred Jealousy Physical Abuser Physical Abuse victim Rage Revenge Unforgiveness Death Issues Abortion (you/spouse/other) Murder Self-Harm/Cutting Suicide Attempt(s) Addictions DEMONIC MANIFESTATIONS Alien Abduction Change in voice Clawing inside Defile Holy objects Convulsions/Seizures Fear anointing oil/Holy water/Salt Foam at the mouth Inability to move/speak Near-Death experience(s) Obscene outbursts Out-of-body experience Possessed by living person See dark shapes/shadows See demons, monsters, or fairies See ghosts/apparitions Spirit possession Smell strange odors Sudden sleepiness UFO sightings Unable to pray or read the bible Unexplained accidents Unknown language spoken Unusual lights Communicating with the dead DEMONIC ACTIVITY Succubus (demonic sexual intercourse with a female spirit) Incubus (demonic sexual intercourse with a male spirit) Feeling cold or having the room become very cold Bites, scratches, or other physical attacks on your body Sleep Paralysis Vomiting/coughing up phlegm in response to prayer Feelings of being choked/unable to breathe when praying Hearing growling sounds inside your head or body Fear or revulsion toward Christian symbols, objects, music, etc. Hearing voices or having thoughts that include suicide, perversion, blaspheme, and wanting to harm others Thank you!
