DELIVERANCE & HEALING INTAKE FORM

Christ came not only to grant eternal life, but also to heal the brokenhearted, liberate humanity from the power of Satan, and deliver from demonic oppression. Through His finished work on the cross, He decisively overcame the works of the devil and secured lasting freedom, restoration, and wholeness. As a ministry, we are committed to partnering with the Lord in His authority and power to extend His healing and to set the captives free, in alignment with Isaiah 61:1

How to Prepare for Your Prayer Session

PERSONAL INFORMATION

Name*

Email*

Phone Number*

Marital Status*

Are you 18yrs or older?*

Have you received Christ as Lord and savior?*

No
Yes
I'm not sure

Do you have a bible?*

Do you attend Destiny Church in person?*

If not, what church do you currently attend?

Do you feel comfortable having a prayer minister of the opposite sex present during your prayer appointment?*

INTAKE QUESTIONS

This form is strictly confidential and will be sent only to Pastor Khristian, who oversees the Transformation Ministry at Destiny Christian Church. The information you provide will only be accessible to:

Pastor Khristian (Transformation Ministries Lead)
The assisting ministry team members present in your prayer session
The designated administrative staff supporting Transformation Ministries

Your information will not be shared beyond these individuals, except as required by law under California’s mandatory reporting guidelines.

Give a brief description of what you’re experiencing that you believe is causing demonic oppression.*

Check ALL that you are currently experiencing or struggling with.

Fear
Anxiety
Depression
Suicidal Thoughts
Anger
Rage
Hate
Unforgiveness
Bitterness
Self Hate
Abandonment
Rejection
Condemning & Negative Thoughts
Abortion (even in the past)
Pornography
Sexual Addiction
Homosexual Behavior
Sexual Lust
Lewdness
Beastiality
Seduction / Promiscuous Behavior
Perversion
Demonic Nightmares
Demonic Torment
I see demons
Heaviness (on or around you)
Impulses to inflict danger to yourself or anyone else
Gluttony
OCD
Unworthiness
Prostitution
Guilt/Shame
Death
Molestation
Rape
Sadness
Murder
Sodomy
Alcohol Abuse
Drug Abuse
Other

Have you experience any of the following?

Witchcraft
Ouija Board
False Religion
Fortune Telling
Psychic Readings
Occult Practice
Crystals
Tarot Cards
Black Magic
New Age Practices
Wicca
Palm Readings
Spells & Curses
Eastern Mediation / Yoga
Psychadelic Drug
Reiki
Mediums / Channelers
Sorcery
Santaria
Watching demonic/Horror Movies

List any other practices, current or past experiences that come to mind that’s not listed above:*

Any childhood trauma/experiences that are not resolved?*

Any unforgiveness/anger/bitterness towards someone that is not resolved? If so, please write the name. Situation will be discussed in prayer session.

Any past or current sin that hasn’t been confessed or addressed?*

Are you able to confess that Jesus Christ is Lord out loud?*

Questions or concerns that you'd like to share before the prayer meeting

If you are able, please fast the meal closest to your appointment.

Everything shared in this form and throughout the prayer session will remain strictly confidential. We have been intentional about cultivating a safe and welcoming environment for you. To protect both you and Destiny’s staff and volunteers, we have established appropriate security measures. Our prayer is that during this process you encounter freedom from bondage, receive healing from every wound, and experience peace and safety in God’s presence.

By signing below, I acknowledge and agree to the following:*

By signing below, I acknowledge and agree to the following:

1. Prayer Setting & Security
- All Deliverance Prayer appointments are conducted with at least two ministry team members present.
- For safety and accountability, video monitoring (without audio) is in place during sessions.

2. Confidentiality
- Personal information shared during prayer sessions is kept strictly confidential within the ministry team.
- Exceptions apply in cases where disclosure is legally required under California mandatory reporting laws (e.g., threats of harm to self or others, child abuse, elder abuse, or dependent adult abuse).

3. Voluntary Participation
- I understand that this prayer ministry/session is not a substitute for professional counseling, medical, or psychiatric care.
- I acknowledge that I am voluntarily seeking this Deliverance Prayer ministry of my own free will and without any pressure, coercion, or undue influence.
- I release Destiny Christian Church, its pastors, staff, volunteers, and representatives from liability for any decisions I make or outcomes I experience following this ministry.

4. Acknowledgment
- By signing, I confirm that I have read, understood, and agree to the above terms and conditions.

I, the undersigned, agree to the terms above.

Once you submit this form, there will be a link for you to click to schedule your prayer appointment.

Almost done. Where should we send the confirmation?

Email*

Name*

Mobile Phone Number*

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