Inner Healing Intake Form

If you are scheduled for an in-person, local, inner healing appointment, please complete the form below.
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Is your relationship with Jesus:
Are you baptized in the Holy Spirit?
Marital Background
If married please rate your marriage on a scale of 1 to 5, 1 being extremely dissatisfied, 5 being extremely satisfied:
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If currently married, have you previously been divorced or widowed?


I've had one or more abortions.
I've had one or more miscarriages.
I've had one or more stillbirths.
I've had one or more children pass away.

Ministry Request Information

Have you received inner healing, regarding this issue, in the past?
Are you currently seeing a counselor or mental health professional?
Are you currently on medication for mental health?
Check the issues that pertain to you.

Family Background Information

Check all that apply:

Idol/ Occult History

Have you ever had your fortune told, had a palm reading, used a crystal ball, consulted tarot cards, played with a Ouija board, followed or read your horoscope?
Have you ever practiced yoga or transcendental meditation or automatic writing?
Have you ever communicated with apparitions that were not of God, including but not limited to attending a seance or a spiritualist meeting?
Have you ever played Dungeons and Dragons, black or white magic games, or played with a voodoo doll?
Do you have any objects(s) or book(s) in your possession that may bring an evil presence or influence with it? Symbols? Dolls? Kits?
Have you ever cast spells or cursed someone?
Have you ever practiced table-lifting, levitation of objects or bodies, or astral travel?
Have you ever worshipped a shrine or object?
Have you ever attended a satanic meeting, voodoo meeting, coven meeting or belonged to a coven?
Have you ever made a promise, pact or blood pact with Satan?
Are you a victim of Satanic Ritual Abuse?
Witnessed or participated in a sacrifice (with or without blood) to any entity or spirit?
Have you been a member of the Masons, Christian Science, Rosicrucian, Jehovah's Witness, Gurus, Mormons, Unification Church, Unity, Scientology, Native Religions?
Have you been in an intimate relationship with someone involved in witchcraft?
Have your parents or ancestors been involved in witchcraft?
Have your parents or ancestors been a member of the Freemasons?
Have you willingly been involved in any addictive or ongoing sin that could bring about oppression in your life such as pornography, drugs, infidelity, etc.?
Have you completed the pre-requisite assignment by listening to the "Father God is Love" message by John Thomas?
Days Available:
Times Available: