Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.About This Form & What You Need to KnowPURPOSE The purpose of this form is to request Deliverance Ministry from Bread of Life. With Jesus guiding the deliverance process, your prayer team will: Recognize any ways the enemy may be influencing, oppressing, or limiting you. Command that presence to leave, and Ask Jesus to fill the void with His love. Please complete this questionnaire to request Deliverance Ministry. DISTRACTION FREE NOTICE To ensure a peaceful and distraction-free environment for everyone during the prayer session, we kindly ask that you make arrangements for your children beforehand, as childcare is not available. If you have someone accompanying you, they are welcome to wait in a separate prayer room during the session. Thank you for your understanding and cooperation! CONFIDENTIALITY NOTICE The information you provide will remain confidential and will be used solely to help us plan and prepare for your session. Only those involved in organizing your ministry team and members of your prayer team will have access to it. DUTY TO WARN/DUTY TO NOTIFY NOTICE We may disclose information without your consent to prevent you from harming yourself or others. We are legally required to report ongoing domestic violence, and abuse or neglect of children, elderly individuals and people with disabilities, including human trafficking. LIABILITY RELEASE NOTICE We will ask you to sign a Liability Release before your session. This is a legal agreement that protects us from being held liable for any injuries, damages, or losses incurred by you during your prayer session. Basic InformationName *FirstLastEmail *Phone Number *YOUR REASONS FOR REQUESTING A SESSION WITH USWhat issues or problems led you to this Prayer Ministry?What have you already done to find healing for these issues or problems? On a scale of 1 to 10, rate how much this is affecting you. Selected Value: 1 (1 means very little, 10 means greatly.) Life ExperiencesHave you or your family members ever experienced the following?Physical AbuseMeMy FamilyNone Known Emotional Abuse – verbal abuse, manipulation, co-dependency, favoritismMeMy FamilyNone Known Sexual Abuse – rape, molestation, incest, unwanted touching, prostitution, trafficking, unwanted visual exposureMeMy FamilyNone Known Violence – beating, stabbing, gunshot, torture, murder, suicide, trauma, kidnappingMeMy FamilyNone Known Incarceration / Jail MeMy FamilyNone Known Addiction – food, alcohol, marijuana, drugs, pain meds, sex, pornography, gamblingMeMy FamilyNone Known AbortionMeMy FamilyNone Known Relational Losses – sudden death, estrangement, abandonment, adoptionMeMy FamilyNone Known Marital / Relationship Problems – separation, divorce, adultery, cheatingMeMy FamilyNone Known Mental Health Problems – depression, anxiety, psychosis, eating disorderMeMy FamilyNone Known Cancer, Serious Health Problems & Lengthy HospitalizationsMeMy FamilyNone Known New Age Spirituality, Occult & Idolatry – fortune telling, divination, crystals, voodoo, hex, Santeria, blood sacrifice, tarot cards, witchcraft, sorcery, spells, incantation, yoga, shamanism, ancestor worship, freemasonry, Ouija Board, Magic 8 ball, seance, or levitation.MeMy FamilyNone Known Are you aware of any curses, hexes and non-Christian “blessings” spoken over you or your family? If yes, describe in detail.Submit