Personal Prayer Ministry

Changing the world
one person at a time…

Confidential Application For Personal Prayer Ministry

Confidential Stamp Image

Thank you for your inquiry! This form will take around 15 - 20 minutes to complete. It will help us to get a better picture of your life situation so that we can better minister to you. Information is kept private. For security reasons, the form should be submitted within one hour or it will eventually time out.

Please note that fields with an "
x" must be filled in. The other fields help us to identify problem areas more quickly but are optional. We only need significant highlights and patterns, not your whole life history. (If you are filling in the form with a cell phone, you may need to turn the phone sideways to see some questions.)

Click "Reset" to clear all fields if desired...


e.g., cell, 123-456-7890

Please spell carefully as a receipt will be emailed to you!

e.g., April 18, 1966

e.g., April 18, 1966

e.g., Mary, 13, John, 12

Only 7 p.m. is available on Mondays. Only 2 p.m. is available on Fridays.


e.g., 3rd out of 5 children

Thank you for taking the time to complete the application.

Our desire is to be as warm and personal as possible. However, those in helping professions need to satisfy the legal requirements of informed consent.

By submitting your application, you are acknowledging that you have read and accept the
legal waivers at this link. (This will open in a new window, which you can close when finished, before clicking the "Submit" button below.)

(If you can't read the code, click on the circular arrows for a new code)