Rapha Appointment Form - Lakemount Worship Centre

Name
First Last
Email
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Session Choice*
Preference for session*
1st choice for an Appointment (please check calendar for availability)
Date Format: MM slash DD slash YYYY
Check all that apply:
- 10:00am
- 1:00pm
- 7:00pm
2nd choice for an Appointment (please check calendar for availability)
Date Format: MM slash DD slash YYYY
Check all that apply:
- 10:00am
- 1:00pm
- 7:00pm
Information
Date of Birth
Date Format: MM slash DD slash YYYY
Gender
Who referred you for ministry?
Have you participated in any other healing ministry? Please list below:
Are you presently seeing a counselor, therapist or psychiatrist?

Additional Information
It would beneficial to consider some type of fasting and prayer the day prior to your appointment. Ask the Lord what He wants you to fast. For example, it could be a meal that day, or a daily activity, in order to use that time for prayer. A non-receiptable donation of $35 is recommended at the time of each application to assist with administrative costs. No one is ever refused on the basis of funds. If donating, please fill in an appropriate amount of your choice and submit the application. You will be directed to make on online payment or you can mail a cheque to: Lakemount Worship Centre, Rapha Prayer Ministry, 54 North Service Rd., Grimsby, ON L3M 1Y8.
Donation Amount
Price: $ 1.00 CAD Quantity:
Enter the dollar amount in the Quantity Field
Date*
Date Format: YYYY dash MM dash DD

Information