In Jesus Name

In Jesus Name

Preaching, Healing and Deliverance Ministry

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In Jesus Name

Christian Prayer, Healing and Deliverance Ministry

In Jesus Name

Christian Prayer, Healing and Deliverance Ministry

Layer 1

CLIENT RECORD CARD

To be completed by the client before deliverance prayer session

Please read and fill this form sincerely and  carefully, in order for us to be able to support you safely. If you do not understand something in this form, contact “In Jesus Name” for advice. The following information is required for your safety, and to benefit your welfare.

The following details will be treated with the strictest confidence and will be viewed only by the individuals involved in personal ministry with you. Confidentiality would only be breached in the cases of emergency (such as your or other’s life or health is in danger.)

Please discuss with your deliverance minister if you need clarification on what are considered emergency situations within the “In Jesus Name” ministry.

    Marital Status*


    Please answer:

    Do you give consent for “In Jesus Name” team to contact you by telephone number provided?*

    Do you give consent for “In Jesus Name” team to contact you via email?*

    Do you give consent for “In Jesus Name” to contact your emergency contact? (ONLY IN EMERGENCY)*


    1. Are you a Christian?*

    2. Why do you need prayer?*

    3. Are you currently taking any prescribed or self-prescribed drugs/alcohol or remedies? (If so then please give full details)*

    4. Are you currently diagnosed with any physical or mental health condition?*

    5. Are you aware of ancestor involvement in any of occult, sexual perversion, alcoholism, mental disorders, adultery, lots of divorce, anger, criminal activity, births out of wedlock, involvement in groups.*

    6. From birth and your early childhood: Are you aware of any trauma you might have experienced during your mother’s pregnancy? Accidents, divorce, spoken words such as “We shouldn’t be having this child”?*

    7. Do you recall any early childhood fears, injuries, nightmares? Do you remember seeing things in your room or feeling an evil presence? Do you recall any encounters of a supernatural kind?*

    8. Any sexual abuse, or sexual embarrassment through childhood?*

    9. Do you recall any emotional, psychological abuse through childhood?*

    10. Have you experienced or currently experience physical abuse from anyone?*

    11. Involvement (however innocently it may have been) with Ouija Boards, Magic 8 Ball, fortune tellers, tarot cards, astrology, horoscopes, levitation games, seances, fascination with books about magic, Harry Potter books, Pokemon cards, physics seers, etc.?*

    12. Movies or TV programs that were particularly frightening to you, or specific scenes that seem to stick in your memory:*

    13. Have you participated in pre-marital sex?*

    14. Period of, or habitual immorality? (including pornography, sexual fantasy, promiscuity. etc)*

    15. What do you think may be the areas of demonic influence in your life?*

    16. Are your parent’s divorced?*

    17. Unusual feelings such as: “Never really felt loved, couldn’t please my parents, feeling worthless?*

      18. Please answer the following questions as they apply to your life:

    18. Homosexual tendencies?*

    19. Have you forgiven everyone?*

      20. Can you forgive?*
    20. Do you have difficulty retaining God’s Word?*

    21. Difficulty reading it?*

    22. Has there been a period of time in your life when you were angry with God?*

    Client’s statement
    I confirm that the information given above is correct and complete and that all answers given by myself to the questions in this form are voluntarily submitted. I will inform my deliverance ministers before receiving deliverance prayer if any of the information above changes at any time prior deliverance prayer. By signing this release, I hereby waive and release, indemnify and forever hold harmless “In Jesus Name” and it’s deliverance ministers, staff, employees and volunteers of any damages, real or perceptual, arising from personal ministry in connection with the information submitted herein.

    I Believe that Jesus Christ is the Son of the living God. He died on the cross and rose back to life on the third day for the remission of sins. I believe within my heart Jesus Christ as my Lord and saviour the only bridge to my salvation and eternity. Jesus Christ ascended back to heaven and is seated at the right hand of the Father. I renounce all false gods and accept the one true God, Father, Son and Holy Spirit. By clicking this agreement I accept my anointing and blessing
    of salvation.