Prophetic Detoxification
In-Take Form

First Name

Last Name

Phone

Street Address

City

Postal / Zip code

Street Address Line 2

Region/State/Province

What is one goal, or outcome you hope to see as a result of this session?

What area of your life, or ministry do you feel stuck?

Can you list/name some of the feelings you have been experiencing related to the area/s where you feel stagnant?

Describe what your prayer time and reading the word is like today.

Have you, or any of your family members been involved in, or exposed to the occult, or any of the following including, but not limited to: Free Masonry, Witchcraft, Fortune Telling, Tarot Card/Palm Readings, Satanism, Eastern Religious Practices and the like?

Is there any other information you would like to share about where you are in your journey?

Have you received deliverance ministry before?

YES

Have you gone through any drastic changes in your life within the past few weeks/months?

YES

Are you a Christian (believer in the power of Jesus Christ to save and deliver?)

YES

Thanks for your feedback!

Prophetic Detoxification In-Take Form

Prophetic Detoxification
In-Take Form