Online Prayer Request Form

Please find below our Online Prayer Request Form for you to fill in and send to us.

Thank you for requesting online prayer. Please fill out the form below and we will be in touch with you as soon as possible to arrange and confirm your appointment.

URL

This field is for validation purposes and should be left unchanged.

Your name(Required)

First name Surname

Your email address(Required)

Your Phone number(Required)

Location(Required)

Please let us know where you are based. eg. Country, city, town etc

Is this your first online prayer session?(Required)

Yes

No

Preferred Day / Days(Required)

Our prayer teams are available to meet with you between the following times. Please select as many days of the week as possible for your online prayer appointment.

Monday 2pm to 4pm

Tuesday 10am to 12pm

Tuesday 2pm to 4pm

Tuesday 7.30pm to 9pm

Wednesday 10am to 12pm

Wednesday 2pm to 4pm

Thursday 10am to 12pm

Saturday 10am to 12pm

Select All

Team members(Required)

Some guests may prefer their two prayer teams members to be of the same gender. Please indicate your preference and we will do our best to accommodate.

No preference

Male only team

Female only team

Medication(Required)

Are you on any medication, or are there potentially complicating issues you feel it would help us to know about?

Yes

No

If you clicked 'Yes' to the Medication Question:

Please give us any details you think may be helpful for us to know about regarding your medication.

Do You Attend a Church?(Required)

Yes

No

If you clicked 'Yes' to the Attending Church Question:

Please let us know which church you’re currently attending.

What would you like prayer for?(Required)

Please specify more details about the reasons for your prayer request (i.e. physical or emotional health challenges). To help our team prepare for their appointment with you.

How did you hear about The Well?

Friends / Relatives

From your GP

Other Organisations

Internet Search

Church or Minister

Please enter these numbers and letters

Request appointment now

Privacy and Safeguarding Policies

Please see the links below to our privacy and safeguarding policies that we have here at The Well, for your information: