Prayer Ministry Questionnaire

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New Users / Returning Users CLICK HERE to setup or return to your account for this form. Creating an account enables you to return to this form and your submitted results. An account will also enable you to partially complete this form and return later to finish the form. The account you establish is only for this form.
Click here for a printable blank questionnaire
Please note that this questionaire and consent form is an opportunity for you to review past events in your life.  Your prayer minister will most likely not review this form before your session.  That way the minister can be led more directly by God.

Contact Information

All information is kept confidential and is seen by prayer ministers only.

Family Information

How was your relationship with your father during childhood? *
How was your relationship with your mother during childhood? *
How was your relationship with your siblings during childhood? *
Which (if any) of the following applied to you during your childhood: *
Status of parents:
Parents religious background:

Personal History

Church affiliation:
Which (if any) of the following have you struggled with either in the past or presently? *
Which (if any) of the following emotions have you had difficulty controlling either presently or in the past? *

Moral Climate

During the first 18 years of your life, how would you rate the moral atmosphere in which you were raised?
Clothing *
Sex *
Dating *
Movies *
Music *
Literature *
Free Will *
Drinking *
Smoking *
Church Attendance *

Medical History

Do you have any addictions or cravings that you find difficult to control?

Personal Experiences

Have you ever been involved in any of the Eastern religions?
Have you ever been involved in or attended meetings conducted by modern cults, such as: *

Informed Consent for Deliverance

I have been informed that the ministry of deliverance is a ministry based in religious belief and is not recognized by the secular field of psychology as a method for the resolution of psychological problems.

I further understand that the session will be conducted by a trained prayer minister. There will also be intercessors present who will be praying for me thoughout the session for God’s healing and direction.

I recognize that this step of faith has been helpful for many but has not been scientifically proven. I understand
that I might experience heightened emotions and memories that were previously unknown or unresolved, that
neither I nor anyone else knew about in advance. I understand that there is a possibility that one or more of
these memories may be screened or false. I will not hold any of the participants responsible for my memories
or behaviors.

I give my consent for deliverance, and am in no way being forced, pressured, or coerced to submit to this procedure from any person or entity. I also have the right to terminate the session at any time without penalty.
I understand that there is no guarantee of continued or ongoing prayer ministry with Aslan's Place staff members.  Aslan's Place staff reserves the right to discontinue a prayer session at any time for any reason as they feel led.

I do understand that if I give any indication that I am currently suicidal or if there is new information about a current molestation of a minor that the prayer minister will report this immediately to legal athorities.

I am entering my name below as a legal acknowledgment that I have been informed of my rights and have had the opportunity to obtain whatever information or professional advice I deemed necessary or appropriate prior to undergoing deliverance.

Please email or call 760-810-0990 when you are ready to schedule your ministry appointment.
Please enter your full name as consent.
Be sure that you have an entry for every question marked with a "*".
The form will not be sent unless all entries are made.