The following checklist has been put together to help both you and your counsellor work through the various roots/issues that must be broken off, renounced, and dealt with. Please note, this checklist is only a guideline. We have tried to cover as many of the major points as possible, however there may [and probably will] be roots/issues in your life that are not listed. We encourage you to list these in the last section of this checklist [blank lines]. If you are not sure of something, we encourage you to list it anyway. This way, you and your counsellor can pray and work through all roots/issues that the Holy Spirit may be highlighting.

In working through the checklist, mark a check if you or your ancestors have had involvement in the point listed. If you are able to answer specifically [if there are several points listed in one box], we encourage you to do so in the space provide.