Survey - Prayer Request and Pastoral Care Form

Prayer Request and Pastoral Care Form

Person Making the Prayer Request

Field Is Required First Name

Field Is Required Last Name

My connection to The Basilica:

Parishioner
Nonparishioner
Affiliated

Field Is Required My Phone Number:

Field Is Required My Email

Information for the Person(s) in Need of Prayer

Field Is Required The person in need of prayer is my: (Select one of the available choices or enter a different value.) The person in need of prayer is my: Click this to indicate that you will select an existing value. Tab to next input." The person in need of prayer is my: The person in need of prayer is my: Click this to indicate that you will enter a new value. Tab to next input." The person in need of prayer is my: Provide your answer here

Field Is Required Name of Person(s) to be prayed for: (Maximum response 255 chars, approx. 5 rows of text)

Field Is Required What is this person's connection to The Basilica?

Parishioner
Nonparishioner
Affiliated

What is this person's prayer need?

Field Is Required Please provide specifics

Illness

Ill, Not Hospitalized
Ill, Hospitalized

Requests Visit?

Yes
No

Hospital or care facility: (Maximum response 255 chars, approx. 5 rows of text)

Deceased

Yes

Date of death:

Are there other bereaved family members that belong to The Basilica?

Yes
No

If so, what are their names: (Maximum response 255 chars, approx. 5 rows of text)

Other prayer need (please specify): (Maximum response 255 chars, approx. 5 rows of text)

Other Pastoral care notes (please specify): (Maximum response 255 chars, approx. 5 rows of text)

How shall we pray for this person?

The person making this request asks that we pray for this person through:

Prayer Line (private prayer circle, only using first names)
Prayers of the Faithful (public mention during Sunday Mass)

On what specific weekend dates? (for Prayers of the Faithful) (Maximum response 255 chars, approx. 5 rows of text)

Field Is Required Do you have the individual's permission to mention his/her name publicly?

Yes
No

Pronunciation (for Prayers of the Faithful): (Maximum response 255 chars, approx. 5 rows of text)