Deliverance Questionnaire

First

Last

Date of Birth

Email Address

Phone Number

Emergency Contact Phone Number

Have you accepted Jesus Christ as your Lord and Savior?

Do you attend a church regularly? If yes, which church?

What Church?

Have you received water baptism?

Have you received the baptism of the Holy Spirit?

What Makes You Feel Unsure?

Have you participated in deliverance ministry before?

How Long Ago and Where?

Have you been diagnosed with any medical or mental health conditions?

Are you currently taking any prescribed medications?

Have you ever been under psychiatric care or taken psychiatric medication?

Do you have a history of self-harm or suicidal thoughts?

Involvements You Have Been In:

SELECT ALL THAT APPLY

Witchcraft / Occult Practices

Freemasonry

New Age / Energy Healing

Tarot Cards / Astrology

Yoga / Meditation (outside Christian practice)

Ancestral Worship

False Religions

Drug or Alcohol Addiction

Sexual Immorality

Other

NONE OF THE ABOVE

Have you or your family experienced generational curses?

Are You Currently Struggling With:

Nightmares / Sleep Paralysis

Uncontrollable Fear / Anxiety

Hearing Voices / Seeing Spirits

Unexplainable Sickness / Pain

Uncontrollable Anger / Rage

Depression / Suicidal Thoughts

Addictive Behaviors

Relationship Issues / Division

Other

NONE OF THE ABOVE

Do you feel tormented or spiritually attacked?

What do you hope to receive from this deliverance session?

Are you willing to renounce sinful practices and unforgiveness?

Are you open to receiving biblical guidance and accountability?

Would you like free access to our course, Deliverance Demystified — a powerful introduction to how and why believers can still face spiritual oppression? (You can start this before your session!)

Awesome! You’ll be given access to our FREE foundational course — Deliverance Demystified.
In this course, we break down what the Bible really says about Christians and demonic oppression, how open doors give the enemy access, and what freedom through Christ truly looks like.

Once you complete this form, you’ll receive an email with your personal link to begin the course.
We highly encourage you to begin the course before your deliverance session — it will equip you with powerful insights and biblical understanding.

Are You Looking For An In Person OR Remote Deliverance Session?

Select Your Deliverance Session Date & Time

I have read and agree to the Terms and Conditions of the Kingdom Alliance Ministries Deliverance Agreement!

Please complete this form prayerfully and honestly before your deliverance session. All responses are kept confidential.

Please complete this form prayerfully and honestly before your deliverance session.

All responses are kept confidential.