Prayer Request and Pastoral Care Form
Person Making the Prayer Request
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First Name
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Last Name
My connection to The Basilica:
Parishioner
Nonparishioner
Affiliated
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My Phone Number:
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My Email
Information for the Person(s) in Need of Prayer
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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:
Please select response
Spouse/Partner
Parent
Child
Sibling
Grandparent
Grandchild
Aunt/Uncle
Friend
Co-worker
Self
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
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Name of Person(s) to be prayed for:
(Maximum response 255 chars, approx. 5 rows of text)
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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:
Month
Jan
Feb
Mar
Apr
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Aug
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Nov
Dec
Day
1
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Year
2038
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1923
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)
Spam Control Text:
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