A2V C1 (HD) HealingDeliverance Ministry - Don't skip question or it won't go through

E-mail Address: *

C1 - First Name *

Last Name

Program Connection:

Sex:

Male
Female

Contact Phone *

What part of the World are you located?: State, Country, etc.

Choose your issues *

Need Healing in Body
Demonic Attack or Witchcraft Attacks
Kundalini Issues
Mental Issues (depression, bipolar, other)
Feel Stuck and blocked in my life, in finances
Rejection (I don't fit in)
I feel abandoned by God
Generational Curses
My generations involved in Freemasonry
Fear and Anxiety due to trauma
Feel hurt from others and feel tormented
I have bitterness towards others
I self-abuse myself
Oppression and Heaviness
Was involved in the occult, new age, and attacked
I was involved sexually and tormented or have guilt
I have uncontrollable sexual appitite
I've been molested and/or raped and feel unclean
I have addictions to either drugs or alcohol
I feel tormented in my thoughts
I cannot get ahead / financial ruins
Other

Need Personal Ministry For: *

Please explain in more detail such as Dr. diagnosis and or symptoms *

Growing Up *

Growing up I could meet my mom's expectations
Growing up I could not meet my mom's expectations
Growing up I could meet my dad's expectations
Growing up I could not meet my dad's expectations
I had an overly strict parent(s)
I had an overly critical parent(s)
I have a hard time forgiving myself for my past mistakes
I grew up walking on eggs around my parent(s)
I grew up in an alcoholic home
I grew up in a drug environment
My mom did not nurture me
My dad was not involved in my life
My parents did not discipline me
My parents did not establish a routine in my life
I felt controlled and put down 50% of the time
I was not planned
I felt like I was a mistake being born
I mom was storng and manipulative with guilt
My dad was strong and manipulative with guilt
I never felt good enough
I was sexually abused in the home
I was sexually abused outside the home
I was verbally and/or physically abused by my dad
I was verbally and/or physically abused by my mom
I feel insecure 50% of the time
I feel worthless 50% of the time
I battle with depression 50% of the time
I have a broken heart
I am performance oriented to feel good about myself to get praise
My parents were not married when I was conceived
My parent(s) - adultery
My parents divorced when I was young
Forced to have an abortion by my parents (boyfriend)
None apply to me

Later Years (marriage, children, divorce) *

My husband/wife manipulated me
My husband/wife physically abused me
My husband/wife emotionally abused me
My husband/wife verbally abused me
I lost a child after birth
I lost a child miscarriage
My husband/wife refuses to work
Moved many times in our marriage because of finances
We loved homeless or lived with family to make ends meet
My husband/wife drinks
My husband/wife does street drugs and legal drugs (addiction)
I ended up divorcing
I'm stuck in the relationship
My husband rapped me
I've lost jobs because of the abuse at home
I have a good marriage
I lived with a man who abused me
I had an abortion
None apply to me

How I feel today about yourself or think *

I don't fit in
I feel insecure
I feel accusation by others
I feel that God has rejected me
I have self-pity
I false burden bearning
Hard for me to make decisions
I suppress my feelings
I have a broken heart from my family
I have a broken heart from my husband/wife
I suffer from self-accusation, self-condemnation, self-blaming myself when things go wrong
Need for love, Approve and Acceptance fro others
Need for identity
I feel despair 50% of the time
I take on false responsiblity
I murmure and complain a lot
Something must be wrong with me
I don't feel like I belong anywhere
I try to meet other people's expectations and feel guilt when others are made or disappoined in me
I'm bombarded with negative thoughts that I cannot control
I am performance oriented to feel good about myself or to get praise from others or at work
I have fear of rejection
I feel like everyone is against me
It matters what people think of me
I get jealous of others
I overthink trying to make a decision or replay hurts
Self-comparing myself to others
Self-critical voice
Self-curse myself when things go wrong
Self-doubt myself
Projecting things to go bad in the future
I get paranoid that people are talkin about me
I have a hard time trusting God - I don't think he is for me or loves me
I get anxious around relationships
I have a hard time saying no when I know I need too - fear of rejection
Excessive worrier
I am highly competitive and cannot lose
I pick fights with people to reject me
I reject others before they reject me
I'm self-centered
Stubborness
Love power and position
I control others so that I don't get hurt
I feel like I've been overlooked
I feel I am stupid
I feel like no one cares about me
I suffer from oppression and heaviness
I am not loved
I feel like I have no value to anyone or God
I live with guilt, shame, and regret from the past
I think about suicide at times
I've tried to take my life
I have a drinking problem
I have addiction to pornogray
I have addiction to sex
I have addiction to gambling
I feel like a victim
I've self-mutilated myself in the past or currently hurt myself when things go wrong
I feel not necessary, important or needed
None apply to me

Are you on prescriptions or taking supplements to bring relief, or other types of treatment? Please list them. *

Did you family members have the same issue? Please list the disease and how they are related *

Did you go through any traumatic events in your life that brought pain, numbness, shock, terror, horror? Please explain otherwise N/A *

You've been hurt by others and feel resentment or bitterness? *

I feel resentful of that person
I feel hurt and want to get even
I intentionally turn away to ignore and avoid him or her
When someone mentiones his or her name it leaves a bitter taste in my mouth
Just thinking about him or her makes me sick to my stokmach
When I think of the person I feel offended
I resent his or her success hearing any good report about him or her
I secretly desire misfortune or failure or worse to come to his or her life
I don't believe I have to forgive them
I know I need to forgive them
I am having a hard time forgiving him or her
I feel separated from God when I pray
I condemn people
I am judgmental and accusatory
I gossip to others about what they did to me
I keep a record of wrong
I feel misunderstood
I feel tormented and cannot stop replaying what this person did to me
I refuse to forgive him or her or them
None of the above apply to me
Make sure you fill out the Bitterness List: https://www.mycontactform.com/hosted/form.php?formid=454737
No bitterness nor resentment

Any Word Curses Spoken Over You? Please list

Any Word Curses You Spoke Over Yourself examle: I am stupid? *

Do you Have a Spirit of Fear *

Fear of Deliverance
Fear of Demons
I suffer from Panic Attacks and Phobias
Fear of Tomorow or the Future
I suffer from Self-Doubt Fear of Making a Mistake
Dread - projecting things to go wrong in into the future
Fear of Change
Fear of the Unknown
Speculative Fear
Fear of Loss
Fear of Losing Life
Fear of Death
Fear of the Dying Process
Fear of Disease such as Cancer
Fear of Losing Children to Death
Fear of Losing Children to the World
Fear of Loss of Relationships
Fear of Chronic Pain
Fear of Emotional Pain
Fear of Disability
Fear of Doctors/Hospitals
Fear of Needles
Fear of Blood
Fear of God in a Negative Way
Fear of God's Punishment
Fear of God's Judgment
Fear of Other People's Judgment
Fear of Losing Salvation
Fear of Fear
Superstition
Fear of Bad News
Fear-Faith (counterfeit faith based on works)
Fear of Betrayal
Fear of Man
Fear of Authority
Self-Consciousness
Felling of Inferiority
Fear of Criticism
Fear of Reproof
Fear of Harrassment
Face Reader and When someone does not look happy afraid it is my fault
Fear of Disapproval
Fear of Verbal Rejection
Fear of Reproached - Being Shamed
Fear of Humiliation
Fear of Bad Choices
Fear of saying the wrong thing where I will look llike a fool
Fear of people finding out my past
Fear of Rejection
Fear of Abandonment
Fear of being aone and loneliness
Fear of not haiving enough of necessities (food, drin, clothing, housing)
Fear of poverty
fear of failure
Fear of losing my mind - insanity
Fear of the dark, night terrors
Fear of antigens
Fear of food, drink, clothes, housing, environment
Fear of chemicals
Gone through trauma where I felt horror, shock, terror, numbness
Fear of noices that cause me to tense up
Fear of animas (snakes, spiders, mice, dogs, etc.)
Fear of being controled and manipulated by guilt
Out of my fear I manipulate and control others
Fear of family members
Fear of spouse
Fear of natural disasters
Fear of water
Fear of war and terrorism
Fear of conflict with others
Fear of authority
Fear of pregnancy
Fear of water and drowning
Fear of heights, bridges, flying, etc.
Fer of being wrobbed
Fear of losing my job
I get anxious around relationships
Fear of COVID? That you don't go out or go to church because of fear unless you have too?
None of the above

In me or my family (envy/jealousy) *

I compare myself to others
I feel the Lord blesses others over me
I covet what others have
I feel discontented with my life
I have a hard time trusting God
I have a critical fault finding spirit or judgmental spirit or it is in my family
I am very competitive with others - some of my family members are
I fight with pride - some of my family are very prideful
I feel superiority over others
I have self-ambition
I strife (fight with others) when they do not agree with me - some of my family members strive
I have jealousy around my spouse
I can be possessive in relationships
I can control, manipulate others - some of my family members control and manipulate
I have inordinate relations - soul ties
I have stolen in the past
I have a hard time when someone gets a promotion - I get jealous
I get suspicious or my family are very suspicious of peoopole
My mom was jealous of me, my brothers or sisters were jealous with me
My family backbitting, belittling, dispute, emnity towards each other
I am boastful
None of the above

Behavior of Accusation *

When someone accuses, I feel I have to defend myself
I feel like the escapegoat
I feel misunderstood with my family
When someone accuses me, I feel I have to fight back
I accuse others
I get offended very easily
There is divorce in my family
I replay what others have done to me over and over again
I feel like the Lord has let me know and I accuse God for my bad fortune
I accuse my parents for my misfortune
When I get accused, I asolate
When others hurt me, I become very deceitful
I have a personality of accusation
I gossip about people
I fault find
I have chaotic thinking
I have scramling thoughts
None of the above

Any Sexual Sins or Other Sins (you: past or present or family): *

I had an affair while married
Mother had an affair while married to your dad?
Dad had an affair while married to your mom?
Living with the opposite sex
Homosexual desires
Multi-partner orgies
Sexual deviation
Pornography onine
Lesbiansm
Pedophilia
Polygomy
Filthy mind
Anal sex
Spirit of perverseness
Exhibitionism
Sexual masochism
Voyeurism
Prostituion
Masturbation
Had an abortion
Forced someone to have an abortion
I wa forced to have an abortion
Your mom had an abortion
Phone sex
Internet sex - pornography
Was in human trafficking
Worked in a strip club - dancer
I'm fluid - both sexes
I used sex as a weapon as controlling others
I've been rapped
I was born out of wedlock - my parents were not married when I was conceived
Watched pornography movies before sex with boyfriend or husband
I love watching people do sex in front of me
I had a divorce(s)
My parents had a divorce(s)
I feel overly sexed - I think about the other peope I've been with even when I have sex with my husband
I feel overly sexed - I think about the men I've been with even though I am not married
Habitual problem with stealing
Habitual problem with lying
Selfish ambition
Drinking problem
Drug addiction (street or prescription drugs)
Fits of rage when I don't get my own way
Bring division to others
Try to control others around me
Have problems with cursing
I am a self-centered person
Gluttony
I have herpes
I have abused others
I have abused others (verbally)
I have abused others (physically)
I have abused others (emotionally)
I have a religious spirit and have made people fall
I have buried my talents
I am cunning and crafty
I am deceitful
I self-injure my body
Other
None

Chose That Pertains to you on core beliefs: *

I must perform to receive praise and love (God or Man)
I only get love in how I act (God or Man)
I must earn it to get love (God or Man)
I must look a certain way to get love (God or Man)
None of the Above

Core - Choose What Apply to You? *

I Am Helpless
I Am Incompetent
I Feel Vulnerable
I Am Not Loveable
I Am Inferior
I Am Not Likeable
I Am UnWorthy
I Am Bad
I Am Stupid
I Am A Burden to Others
None of the Above

Core: Did my experiences lead me to think there was something wrong with me in some way? If so, what was wrong? *

Yes
No
Sometimes
None at all

Core - Do you remember specific situations that accompany the negative thoughts or feelings you have about yourself? What memories of these situations say about you as a person? *

Core: Can I link a specific person I know to the way I feel about myself? Has that person used certain words to describe me? What does their treatment of me say about me as a person? *

Core: What are the common themes, labels, words, or names I use to describe myself? What do they mean about me? Or Negative Words Others Spoke Over You that You Still Replay or Believe? *

Occultism (Check if past, present, or Family Involvement) - Part 1 *

American Indian Ceremonies
Sweat Lodge
Powwows
Dream Catcher in Your home
Medicine wheel
Angel worship - you pray to angels
Yoga of any type even Christian
Ascended Masters: Elizabeth Clair Prophet
Astral Projection
Astrology
Horoscopes
Zodiac Signs
Aura Reading
Automataic Writing
Chanting / Mantras
Charms: Ankh, Tailsmans, Indian Horns, Horseshoe, Rabbit's Foot, Scarub
Energy Balancing: Chi, Ying and Yang, and Other
Clarvoyance: Clair Audience, Mental Telepathy, ESP
Colorology
Conjuration: Incantation, Channeling, Mediums
Course of Miracles Helen Schumann, Kenneth Wapnick, Gerald Jampolsky and others
Crystal Balls / 8 Balls
Pagan Ceremonies
Death / Dying Movement: Eliizabeth Kubar-Ross, Tibetan Book of the Dead, Into the LIght, and others
Deja Vu experiences
Divination: Tarot Card Reading, Fortune Telling, Tea Leaf Reading, Handwriting Analysis, Palm Reading, I Ching, Numerology, False Prophecy, Other
Dream Work: Jungian, Sinoi
Drug Trips, Recreational Drugs to connect with the universe
Dungeons & Dragons, Other Fantacy Games, Magic
Ekankar Follower
Eniagrams
Familiar Spirits
Necromancy, Family Spirits, Seances, Table Tipping or Knocking, Spiritism
Feminism, Goddess Worship, Worship of the Earth
Fetishes, Power Objects
False Prophets: Jean Dixon, Nostradamus, False Prophets in the Church
Feng Shui
Financial bondage to the occult
Fire-walking
Gurus, Transcendental Meditation, Hare Krisnas, Deepak Chopra, Self-Realization Fellowship
Humanism: Human Potential Movement, Actualizations, The Forum, LIfe Spring, Christian Version of Life Spring, EST (Erhart Seminar Training)
Hypnotism
Self-Hypnotism, Subliminal Tapes
Incense, Moxibustion
Inner Peace Movement
KKK, Racism
Magic: Black, White, Stage Magic
Martial Arts: Tai Chi, Karate, Judo, Kung Fu, Aikido, Others
Mediums: Edgar Cayce, Arthur Ford, JD Knight, Swedenborg, Jane Roberts, Others
Metaphysics
Mind Idolatry / Mensa
New Age Thinking
New Signs of the New Age: Unicorns, Rainbows, New Age Symbols, Rock Music, Hippie Memorabilia
Occult or New Age Books
Occultic Fictional Characters: Elves, Genies, Leprechauns, Easter Bunny, Mother Earth, Gaia, Tooth Fairy, and more
Occult Music: Demonic Rock, Stephen Halpern, Sam Dancing, Other
Occultic Virtual Reality
Ouija Board
Pagan Religion/Paganism in Christianity - self thought
Parapsychology
Pilates
Poltergeists
Psychic reading / Psychic Portraits
Rebirthing
Reincarnation / Past Life Regression
Satanism: Satan Worship, Halloween, Pentagrams
Science Fiction: Star Trek, Star Wars, UFO's, Aliens, The Force, Others
Shamanism / Carrols Casteneda
Others Not Listed
None

Check if past, present, or family involvement - Part 2 *

Silva Mind Control, Mind Dynamics
Sorcery / Pharmakeia
Spiritism / Spirit Guides
Status of Idols: Diana, Angels, Mercury, Venus, Buddha, Idolization of Movie Stars, Musicians, Athletes, Gurus
STongehenge, Machu Picchu, Gone to Hindu Temples, Buddha or Muslim Temples
Superstition: Fear of Black Cats, Wishing on a Star, Friday the 13th, Salt over the Shoulder, and other
Theosophy: Allice Bailey, The Plan, Theosophical Society, Annie Besant, HP Blavatsky, Krishnamnuri
Transcendental Meditation, empying the mind
Soaking Prayer, Centering Prayer
Voodoo, Santaria, Voudon
Waterwitching / Geomancy
Warlock, Male and Female Witch, Involved in Wicca
A time you didn't believe in Jesus
Witchcraft: spells, potions, photos to cast spells of bad to someone, curses - that you have done
Jezebel / Ahab Spirit: Control and Manipulation, Passive, Matriarchal Witchcraft - Controlling others or allowing others to control you
Kundalini / Chakra cleansing opening, Opening up third eye through tapping, Tantra, Kamasutra
Inner Healing - going back to your pain, and calling Jesus into your pain
Fire tunnels
Satanic bible in your home
Occult books in your home
Freemasonry bible or other modalities
Family members in Freemasonry
Other Stuff
None of the above in my life or my generations

Check False Religious Practices (yourself past or present, family involvement - Part 3 *

Eastern Philosophies
Hinduism
Gurus
Bahaism
Buddhism
Zen, Vipassana, Tibetan Buddhism
Cabala / Jewish Mysticism
Scientology
Secret Brotherhoods / Sisterhoods - Fraternities and Sorities, Blood Oaths
Rosicrucianism
The Way International
Unification Church - Moonies
Urantria
Family members in Freemasonry
Eastern Star - yourself or family members
Rainbow Girls
Elk Lodge
Orange Lodge
Independent Order of Odd Fellows
Ancient Order of the Foresters
Mormonism
Latter Day Saints
Other
None

If involvement in the occult, witchcraft, new age, and new age medicine, check symptoms you are dealing with today - Part 4 *

Deep confusion
Convulsions (epileptic seazures
Sometimes hatred of God
Distrust of God
Inability to sleep
Night torment or terror
Hostility and agression
Impatience
Control of others
Suspicion (Paranoia)
Frustration
Feeling insane like you are losing your mind
Depression more than 50% of the time
Heaviness and Oppression
Tormenting thoughts
Certain types of pain especially in relationships to the central nervous system - unexplained pain
Out of body experiences
Division maker and trouble maker
Obsessions to others or things
Inability to hear God's voice
Falling asleep in church
See Orbs
Seeing ghostly figures
falling asleep while reading the bible all the time
Rebellion against God no matter how hard you try to be obedient
Stubborness
Disobedience to God's Word as a chronic activity
I feel like knives are stabbing me
I feel movement in my body like a snake
Inability to develop a prayer relationship with God
I have made vows not to be like my mom or dad
I have self-cursed myself - self-accusations
I wish I could die
Sicknesses that doctors cannot figure out
Feeling scratches and wake up with scratches on my back, or arms or legs
Blasphemy of God, the Holy Spirit
Other
None

New Age Medicine for Divine Healing (past, present, or family members) - Part 5 *

Acupuncture
Ayurveda
Homeopathy
Naturopathy
Chinese or oriental medicine
Body movement therapy
Tai Chi
Electromagnetic therapy
Reiki
Qigong
Quantum healing
Biofeedback
Vusual and guided imagery
Chelation therapy
Craniosacral therapy
Crystal healing
Cupping
Dowsing
Magnetic therapy
Shiatsue
Therapy touch
Energy psychology
Feng Shui
Graphology
Isolation tanks
Isopathy
Iridology
Light therapy
Five elements
Flower essesnce therapy
Bach flower therapy
Messages from new agers
New thought
Nature therapy
Pranic healing
Reflexology
Rolfing structural integration
Recreation therapy
Radonics
Sound therapy
using vitamins and herbs for divine healing
Trigger points
Water cure
Other
None

Any other new age, witchcraft, occult, false religious practicesj, new age medicine you did in the past or present, or family members? If so, please write or if none type N/A in space *

When did you totally surrender to the Lord *

Are you spirit filled? *

Do you tithe? *

Yes
No
Sometimes
I don't believe in Tithing

Do you go to church almost every week or more? *

Yes
No
Not since covid and watch it on TV

Next Form: Liability Form If It does not take you to that page *

Anything Else You Want to Explain? *

* Required