Deliverance Request Form | The Apostles House

The Apostles House Deliverance Ministry Request Form

DELIVERANCE REQUEST FORM

Confidential – For Pastoral Review Only

Deliverance ministry at The Apostles House is conducted with prayer, biblical guidance, and pastoral oversight. Completion of this form does not guarantee an appointment, but allows leadership to prayerfully review your request and determine the appropriate care.

Personal Information

Full Name

Date of Birth

Multi-line address

Country/Region

Address

City

Zip / Postal code

Emergency Contact Name

Emergency Contact Phone

Are you currently a member of The Apostles House?

Yes

No

Visitor/Guest

If not a member, how did you hear about our deliverance ministry?

Spiritual Background

Are you a believer in Jesus Christ?

Yes

No

Unsure

Have you been baptized in water?

Yes

No

Have you been baptized in the Spirit?

Yes

No

Are you currently attending a church?

Yes

No

If yes, church name.

Pastor/Leader (if applicable)

Reason for Deliverance Request

Please briefly describe the reason you are requesting deliverance ministry.

Spiritual Experiences & Concerns

Have you experienced any of the following?

Other Concerns

Past Spiritual Involvement

If yes, please explain

Previous Deliverance Ministry

Have you received deliverance ministry before?

Yes

No

If yes, when, where and what was the outcome?

Mental & Emotional Health

This section helps ensure the appropriate pastoral care.

If yes, please explain

Are you currently under the care of a therapist, counselor, or psychiatrist?

Yes

No

Are you currently taking medication for mental health?

Yes

No

Personal History (Optional but Helpful)

You may briefly describe if you feel comfortable:

Commitment to the Deliverance Process

Deliverance is not a quick ritual but a process of repentance, renunciation, and spiritual growth.

Please check the following:

I understand deliverance is based on biblical principles

I am willing to participate in prayer, repentance, and forgiveness.

I understand that leadership may recommend counseling, pastoral care, or discipleship as part of this process.

I understand that this ministry does not replace professional medical or psychological care.

Release & Content

I voluntarily request deliverance ministry from The Apostles House. I understand that this ministry is spiritual and pastoral in nature and not a substitute for medical or psychological treatment.

Signature

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