Healing Registration This form is designed to collect personal information for individuals seeking healing ministry. Please fill out all required fields accurately. Step 1 of 8 - General Information 12% Name of Party in Distress(Required) First Last Name of Person Making Request or Referral (if different) First Last Complete Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cell Phone of Person Seeking Deliverance(Required)Cell Phone of Person Making Request (if different)Email Address of Person Seeking Deliverance(Required) Email Address of Person Making Request (if different) Person’s Date of Birth(Required) MM slash DD slash YYYY Marital Status(Required)Never MarriedMarriedCohabitationWidowedSeparatedDivorcedDivorced and Remarried, without AnnulmentDivorced and Remarried with AnnulmentHow Many Times Have You Been MarriedCurrent Spouse’s NameWere You Married in the Catholic Church?(Required) Yes No How Would You Describe Your Marriage?Number of Children(Required)Names and Ages of ChildrenAre Any of Them Baptized or Have Received Any of the Sacraments?(Required) Yes No Presently Living With(Required)What is Your Primary Language?(Required)What Other Languages Are You Familiar With? (Please note fluency and level of understanding)(Required) Describe Your Support System and Who Would Be There in Your Time of Need(Required)Parents' Marital Status(Required)MarriedSeparatedDivorcedRemarriedYour Age at DivorceYou Lived With(Required)Both ParentsFatherMotherStep Parent(s)Foster Parent(s)OtherFather Deceased?(Required) Yes No If Yes, How Old Were You at His Death?Type of DeathMother Deceased?(Required) Yes No If Yes, How Old Were You at Her Death?Type of DeathDo You Feel That Your Emotional Needs Were Met by Your Father?(Required) Yes No Do You Feel That Your Emotional Needs Were Met by Your Mother?(Required) Yes No Do You Feel That Your Spiritual Needs Were Met by Your Father?(Required) Yes No Do You Feel That Your Spiritual Needs Were Met by Your Mother?(Required) Yes No Do You Feel That Your Physical Needs Were Met by Your Father?(Required) Yes No Do You Feel That Your Physical Needs Were Met by Your Mother?(Required) Yes No Three Words That Characterize Your Relationship with Your Father(Required)Three Words That Characterize Your Relationship with Your Mother(Required)Do You Have Clear Memories of Your Childhood?(Required) Yes No Are There Any Gaps in Your Childhood Memories? If So, At What Age?(Required)Do You Have Any Enemies or People Who Would Want to Hurt You?(Required)Describe Your Friends and How Many Close Friends You Have(Required)Have You Had Any Friends Abandon or Reject You?(Required) Yes No Do You Feel That You Have Difficulty in Making or Keeping Friends?(Required) Yes No Is There Any Family History of Addiction, Usage of Drugs, Depression, Suicide or Other Mental Health Disorders? If So, Please Explain.(Required) Highest Level of Education(Required)High SchoolSome CollegeBachelor's DegreeGraduate DegreeIf Graduated from College, Indicate Level of Degrees and Type, and Any Clubs or FraternitiesAre You Baptized?(Required) Yes No If So, Church Name and Denomination(Required)If Catholic, Have You Been Confirmed and Received First Holy Communion?(Required) Yes No Did You Take Any Theology or CCD Classes Growing Up?(Required) Yes No Did You Attend a Catholic or Private School?(Required) Yes No Current Religious Affiliation(Required)CatholicProtestantNoneOtherAre You Practicing?(Required) Yes No If So, How Involved Are You and How Often Do You Attend Worship Services?(Required)How Often Do You Attend Sunday Mass and Other Masses?(Required)How Often Do You Attend Confession and When Was the Last Time You’ve Been to Confession?(Required)Do You Pray Regularly?(Required) Yes No If So, Explain Your Prayer LifeDescribe Your Relationship with GodDo You Have Any Devotion to Saints? If So, Who?Do You Experience Any Difficulty During Prayer or Receiving the Sacraments?(Required) Yes No If So, Please Elaborate(Required) Describe Your General Health(Required)Any Psychiatric or Mental Illness Diagnosis by a Medical Provider?(Required) Yes No Have You Ever Been Evaluated by a Psychiatrist or Therapist?(Required) Yes No Are You Currently Receiving Counseling or Psychiatric Care?(Required) Yes No If So, When and For How Long?Have You Ever Been Hospitalized for Psychiatric Reasons?(Required) Yes No If Yes, Please Explain(Required)When Did You Receive Your Last Physical Exam?(Required) MM slash DD slash YYYY Name(s) of Doctor(s) I Am Currently Receiving Care From(Required)Are You Willing to Obtain Those Records for Us or Sign a Release of Information for Them?(Required)Please List All Medications You Currently Take and the Dosage(Required)Has There Ever Been the Use of Psychotropic Medications?(Required) Yes No If Yes, Please Include Type, Dosage, and LengthDo You Suffer from Any Addictions?(Required) Yes No If Yes, Please ExplainIs There Any Current Alcohol or Drug Usage?(Required) Yes No If Yes, Please Include Type and Frequency Please Check and Rate the Severity of Each Applicable Area (1 = Low, 5 = High)(Required)12345DepressionChronic IllnessSexual ProblemsMarital ProblemsAnxiety or FearLonelinessDrug AddictionsNightmaresInsomniaEating DisordersAlcoholismAngerWorkaholismGrief or LossLow Self-EsteemHear VoicesRestlessnessLost Job(s)Inability To ForgiveSee ShadowsLost RelationshipsFinancial ProblemsDespairCryingIsolationAny type of self harmUnexplained PainIs There Anything That You Want to Explain from What You Have Checked Above?Have You Ever Had Any Suicidal Thoughts or Attempted Suicide?(Required) Yes No If Yes to the Thoughts, When Was the Last Time You Had Them and How Frequent Are the Thoughts?(Required)If Yes to the Attempt, How Many Times and When Were They?(Required)Did You Ever Speak with Anyone About This?(Required)Do You Ever Just Lose Blocks of Time? If So, Please Explain(Required)Do You Ever Believe That You Have Spent Time as a Different Persona? If So, Please Explain(Required)Have You Ever Had an Abortion?(Required) Yes No If So, How Many? Describe What Brings You Here TodayWhat Current Issues Lead You to Believe That You're Demonically Oppressed, Obsessed or Possessed?Duration of Present Issues (in weeks)Are You Experiencing Any Demonic Manifestations? What Are They?Have You Sought Help for This Matter Before? If So, From Whom?Prior to Today, Have You Sought Any Help from the Church for Other Matters? If Yes, Why, What Church, and What Priests?Have You Ever Been Prayed Over by a Prayer Team, Deliverance, and/or Healing Team?(Required) Yes No If So, Why, What Church, Who Was Involved, and Do You Remember Any Prayers That Were Used?Have There Been Any Traumatic Moments in Your Life or Trauma That You’ve Witnessed?Have You Witnessed or Experienced Any Abuse? (Physical, Sexual, Verbal, etc.)(Required) Yes No If Abuse is Indicated, Was This Reported to Local Officials? Which Agency, City, etc.? What Became of the Report?Age of Event/DetailsHave You Ever Received Help from Anyone for This? If So, Who?Have You Ever Been in Prison or Incarcerated?(Required) Yes No If So, When, For How Long, and Where? Have You Ever Dabbled with Any of the Following? Please Check All That Apply.(Required) Ouija Boards Séances Tarot Cards Horoscopes Psychic Powers Wicca Witchcraft/Brujeria Fortune Telling Satanism Voodoo/Santeria Astrology Palm Reading New Age Freemasonry Channeling Cult Involvement Past Life Recovery Visited Healers Curanderos Astral Travel Ana/Evil-Eye/Anti-Evil Eye Other None If You Have Checked Any of the Above, Please Explain and Describe the ExperiencesHave Any of Your Family or Friends Been Involved in Any Occult Activities?(Required) Yes No If Yes, Describe the Object and Where It Is NowHave You Ever Cursed Yourself or Made Vows to Yourself? Please Describe ThemHave You Ever Cursed Anyone? Please List Any Judgments About Others That You BelieveDo You Believe That You Are the Victim of a Curse?(Required) Yes No Do You Believe That People Have Their “Eye” on You?(Required) Yes No The Following Symptoms May Indicate Spiritual Oppression. Please Check Any That Relate to Your Experience.(Required) Psychic abilities, clairvoyance, divination Inward perception of a separate personality, name or voice Fearful, repetitive night visitations by an evil presence Difficulty participating in prayer; agitation, nausea, anger, rebellion, etc. Uncontrolled thoughts/impressions; i.e. sexual perversion, cursing, violence Uncontrollable compulsive behaviors: sexual sin, anger, chemical indulgence Preoccupation with thoughts of death, despair and hopelessness Uncontrollable, irrational, paralyzing fear Unusual, non-typical emotional expressions, i.e. laughter, sadness, crying, anger Extreme nervousness or negative reactions at the mention of the name of Jesus None Anything Else That You Want to Mention? If no please type none(Required)How Many Sexual Partners Have You Had?(Required)Any Same Sex Partners?(Required) Yes No Any Sexual Encounters with Multiple Partners Simultaneously?(Required) Yes No If yes, how many?(Required)Do You View Pornography and/or Masturbate?(Required) Yes No If So, How Frequent for Each One Respectively?(Required)Have You Read the Works of Exorcists?(Required) Yes No Do You Truly Want to Be Free from the Evil Influences Presently Affecting You?(Required) Yes No Are You Willing to Make the Sacrifices Necessary to Move You Towards Freedom?(Required) Yes No Are There Any Fears, Reluctance, or Hesitancy to Being Free? If so, please explain.(Required) Δ
