The Official Real Deliverance Ministry

COUNSELOR QUESTION SHEET

For Spiritual Warfare and Discovering Open Doors for Demonization

Prepared by Bill Niland
This sheet will help disclose demon strongholds and legal rights. It will print up for you in about 3 sheets. Print it and send it to me by mail, or copy and paste, fill it out, and send it via e-mail. Click here for mailing addresses. Don't know how to copy and paste? Read our easy instructions.

PERSONAL INFO

Date_____/______/_____Name______________________________ Age ___

Phone( _____) ________-_________Email Address ______________________________

Referred By________________________________________

Church Affiliation (if any)________________________________Year saved ______ Age when saved _____

Please answer this question> How do you know you are saved? Why/why not? YOU MUST ANSWER THIS

________________________________________________________________

PERSONAL SIN ISSUES (what are you struggling with now?)

1) ___________________________________ 4) ___________________________________

2) ___________________________________ 5) ___________________________________

3) ___________________________________ 6) ___________________________________
EMOTIONAL PROBLEMS Check all that apply:
__ Depression__ Anger toward whom? ______________ __ Rage toward whom? _______________ __ Suicidal__ Hate toward whom? _______________

__ MPD/DID__ Unforgiveness / toward whom? _____________

CONFLICTS WITH PEOPLE

Do you have any conflicts in your family relationships? _____If yes, who is the conflictwith? ________________________________________________________

Do you have any conflicts with another person or persons besides your family?

If yes, explain _______________________________________________________

EXTREME OR ABNORMAL CONDITIONS: Check all that apply:

__ Fear__ Resentment __ Self-pity__ Bitterness __ Envy __ Racism

__ Pride__ Anti-Semitism__ Jealousy__ Unbelief__ Unpredictability__ Doubt __ Other _______________________

Discontentment with: __Self __Spouse ___Family __Friend__ Circumstances __Other __ Self-punishment:

__ Mental (describe)__________________________________________________

__ Physical (describe) ________________________________________________

__ Other conditions: __________________________________________________

TRAUMATIC EXPERIENCES

Check all that apply:

__ In childhood

__ Teenage

__ Adulthood

__ Abortion

__ Murder

__ Rape

__ Incest

__ Molestation

__ Sexual Abuse

__ Emotional Abuse

__ Controlled by Another

__ Sudden death of a loved one

__ Physical attack

__ Other ___________

___________________ ___________________

DESTRUCTIVE HABITS: Check all that apply:

__Lying__Lust__Gluttony__ Blasphemy__ Anorexia / Bulimia __ Cutting

__Smoking__ StealingÂ __ Temper __ Drinking __ Constant criticism

__ Drugs__ Gossiping__Homosexuality__Other__Addictions_________________________________

IMMORAL CONDITIONS: Check all that you have done or participated in:

__ Homosexuality/Lesbianism __ Adultery__ Masturbation__ Fornication (sex while unmarried)

__Pornography__Bi-sexuality__Incest__Sodomy __ Rape

__ Indecent Exposure __ Bestiality__Other: ____________ - ___________ - _______________

__ I have the desires for these sorts of things listed, but have not acted upon them. List which one(s): ____________________________

__ I have pictures/videos/books of the above nature. List which one(s): ________________________________________

SOUL TIES. A soul tie is any un-Godly relationship. Examples: certain friends, family members, witches, etc. Anyone not Christ-minded.

__ Emotional With whom? __________________________________________

__ Sexual With whom? _____________________________________________

__ Other With whom? _____________________________________________

OCCULT ACTIVITY PAST OR PRESENT

1) Have you ever sought--or been subjected to as a child HEALING, through magic conjuration and charming, such as:

__ Removal of warts, burns, or diseases__ Treated by or through a spiritualist__ Christian Scientist __ Spirit healer __ Psychic healing __ Hypnosis

__ Metaphysical healing__ Any evil doctrine __ Use of the pendulum __ Divining (e.g. water witching rods, wedding ring, needle and thread, etc.---all forms)

2) Have you ever practiced: __ levitation or __ automatic (spirit) writing?

3) __ Have you ever used or worn an amulet, talisman or rabbit's foot (any good luck charms)? __ Have you ever used or worn any magic charms?

4) Have you ever had acupuncture? __ Based on lines similar to the zodiac__ Any other sort __________________________________________

5) Are you involved in celebrating Halloween trick or treating? _______

6) Ever been involved in martial art in any form? _______If so, what form? ________________________________

7)Have you ever:

__ practiced meditation __ had a spirit guide (either now or in the past) __ practiced mental suggestion __ cast a magic spell (even in fun)

__ practiced telepathy__ had E.S.P.

8) Have you ever participated in:

__ Satanism __ Witchcraft /Wicca__ Vampirism/Blood drinking __ Angel worship__Mother earth

__ White magic___Black magic__ practicing medium __ Blood spilling __ Chain letters

9)Have you ever visited or used: __ A Psychic__ A Palm readerÂ__ Hypnosis __ A Crystal ball gazer __ Tea leaves__ Horoscopes

__ Tarot cards __ Yoga__ A spiritist meeting __ A Ouija Board __ A life / reincarnation reading

__ A Psychic Analyst __ Other __________________________________________

10) Have you had an: __ Imaginary Playmate __ or any Spirit visitors

ARTICLES OR ARTIFACTS WHICH MAY BE PRESENT IN YOUR HOME

__ Tarot cards __ CrystalsÂ __ Energy balls __Occult Jewelry ___Occult carvings __ Occult or pagan religious objects

__ Games of occult nature__Harry Potter books ___Poke'mon/Digimon/Yugi o/ B-Damons Toys/etc.

__ Good luck charms___ amulets __ Heavy Metal or Rap music

__ Any Pagan god images (Buddha, Sun god, Egyptian, etc.)

__ Relics or artifacts that may have been used in pagan temples and religious rites or in the practice of sorcery, magic, divination, or spiritualism.

__ Any and all Indian religion items (dream catchers, peace pipe, anything with attached belief systems to it) (Indian religion is witchcraft)

__ Graven images of God (pictures of Jesus, Jesus on a cross, etc.)

Do you have books, comics, or videos on: __ Vampires __ the weird__ Horror

Do you read or have in your home any occult, spiritualist, or new age books such as:

__ Books on astrology __ Interpretation of dreams_ Metaphysics __ Self-realization __ Fortune telling

__ Black magic __ E.S.P.__ Clairvoyance __ Psychic phenomena __ Mind control __ Meditation

__U.F.O.s __Newagehealing __Altered states of consciousness __ Other ______________________________

Any and all Catholic items (rosary, crucifix, statues, etc.) _____________________________________

Halloween items and decorations ______

FALSE RELIGIONS WITH WHICH YOU HAVE BEEN CONNECTED

__ Herbert W. Armstrong__ Hare Krishna __ Scientology__ Buddhism__Mormons __ Catholicism__ Orthodox__ Christian scientists

__ Jehovah Witness __Unitarian __Evolution theory __Muslim ___Charismatic/Pentecostal ___Word faith movements

__Other:_________________________________________________________

****False "so called Christian"teachers: (That you subscribed to their teachings)

__Joel Osteen __Joyce Meyers __Benny Hinn__Rod Parsley __Rodney Howard Browne __Kenneth Copeland __Crefflo Dollar __Mike Murdock

__Paula White -Other: ___________________________________

If you need more info about these and other false teachers, please go to http://www.letusreason.org/Popteach.htm

Have you or your family, now or in the past, been involved in:

__ The Masonic Lodge __ The IlluminatiÂ __ Eastern Star __ Shriners

__ or any other secret society: ______________________________________________________

DRUGS AND ALCOHOL ABUSE

Are you, or have you ever been, a drug user or pusher? ________ List drugs___________________________________________________

Are you an Alcoholic? ______

CONDEMNATION GUILT

__ In regard to past sins __ Fear of committing sins__ Unforgiveness (as expressed in anger, etc.)_ Fear of being unforgiven

__Divorce/remarriage __so-called-Unpardonable sin(In reality, it is denying Christ as Savoir)

__ Abortion __ Other __________________

Explain checked answers here: ___________________________________________________________________________________

GENERATIONAL SINS (SINS OF THE FOREFATHERS) Many demons work legally through the generational sins. List all the sins of the forefathers and compare with sins and strongholds you checked above. What same sin(s) do you have that either of your parents have? List below:

MOM'S SIN ISSUES __________________________________________________________________

DAD'S SIN ISSUES ___________________________________________________________________

GRANDPA (Mom's side) _______________________________________________________________

GRANDMA (Mom's side) _______________________________________________________________

GRANDPA (Dad's side) ________________________________________________________________

GRANDMA (Dad's side) _______________________________________________________________

OTHER NOTES AND COMMENTS

___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________