Deliverance Request

About This Form & What You Need to Know

PURPOSE

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 Information

Name

YOUR REASONS FOR REQUESTING A SESSION WITH US


Selected Value: 1
(1 means very little, 10 means greatly.)

Life Experiences

Have you or your family members ever experienced the following?

Physical Abuse

Emotional Abuse – verbal abuse, manipulation, co-dependency, favoritism

Sexual Abuse – rape, molestation, incest, unwanted touching, prostitution, trafficking, unwanted visual exposure

Violence – beating, stabbing, gunshot, torture, murder, suicide, trauma, kidnapping

Incarceration / Jail

Addiction – food, alcohol, marijuana, drugs, pain meds, sex, pornography, gambling

Abortion

Relational Losses – sudden death, estrangement, abandonment, adoption

Marital / Relationship Problems – separation, divorce, adultery, cheating

Mental Health Problems – depression, anxiety, psychosis, eating disorder

Cancer, Serious Health Problems & Lengthy Hospitalizations

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.