Roots&Branches Appointment Request
Please complete and submit this form to request a listening and healing prayer session.
Name (first and last) *
Your answer
Street address *
Your answer
City, state and zip code *
Your answer
We will contact you to schedule and confirm appointments by email. Please provide your email here. *
Your answer
In the case of a last minute change, is it OK to leave a message on your cell phone?
Cell phone number
Your answer
Emergency contact name *
Your answer
Emergency contact phone number *
Your answer
Date of birth *
Your answer
Marital status *
Your answer
If you have children, please list the number of children you have and their ages. *
Your answer
Are you currently employed? *
Do you regularly attend church? *
Where do you attend? *
Your answer
How did you hear about Roots&Branches? *
Your answer
Are you now or have you been in counseling previously? *
Are you in the care of a medical doctor? *
If you are in the care of a doctor at this time, please briefly explain why.
Your answer
Are you currently taking psychotropic medications? *
Please name two emotions that describe how you are feeling right now. *
Your answer
Please summarize the physical, emotional, and/or spiritual needs that bring you to Roots&Branches. *
Your answer
Roots&Branches appointments are offered during the hours listed below. Sessions last between 60 and 90 minutes. Please check the options that work best for you. Our prayer room coordinator will email you to schedule your appointment based on your availability. (If you have not heard back from us within 36 hours, please check your spam folder.) *
Required
We are currently able to offer a limited number of sessions Mondays, 7:00 pm, at Crossroads Mason prayer room. If this time is available, would you prefer this to the options listed previously?
Our ministry teams consist of two to three people. To help us make your healing appointment as comfortable as possible for you, please indicate if you have a preference for your team. *
Informed Consent
I understand that Roots&Branches listening and healing prayer teams give their time, compassion and love solely as caring lay people. As non-licensed persons, we offer no counseling or professional psychological expertise.

The ministry of Roots&Branches does not offer professional, medical, or psychological care. We never advise anyone to stop taking medication. It is the responsibility of the seeker to inform their practitioner of their participation in Roots&Branches ministry. It is also the responsibility of the seeker to adhere to the recommendations of their professional caregivers. We will coordinate healing prayer with the care of professional counselors and caregivers at the seeker’s request and with written permission from the seeker.

The content of all sessions is strictly confidential and will not be discussed outside ministry leadership. Exceptions to this would be if your prayer ministers have reason to believe that you are at risk of hurting yourself or another, or if there is a reason to suspect child or elder abuse/neglect. In these instances, the necessary authorities or persons must be notified by law.

I understand that this ministry uses volunteer prayer ministers who have completed the Roots&Branches training program. As such, they are required to consult periodically with ministry leadership. I give my permission for my prayer ministers to discuss my prayer needs with appropriate staff as necessary.

If I have any questions concerning my prayer minister's training, experience or qualifications, I have the right to consult with the Roots&Branches staff. As with any other volunteer religious organization, it is my choice to take any suggestions, teaching, or prayer of the ministry under consideration and apply it appropriately. If at any time I feel offended by anything my prayer minister asks, says, or does, I acknowledge that it is my responsibility to report it immediately to Roots&Branches staff.

I may have up to five visits with my prayer team. At any point, my prayer team will reassess with me the need for additional ministry or referral.

I have read and understand the above and consent to receiving help through the Roots&Branches Network for Healing and Growth.

I have read the Informed Consent and consent to receiving help through Roots&Branches. *
Sign by printing your full name *
Your answer
Date of agreement *
Your answer
Making the suggested donation for your session
Roots&Branches suggests a minimum donation of $40 for prayer room appointments. Donations are requested at the time appointments are made and can be made online here: https://squareup.com/store/roots-and-branches-network or www.rootsandbranchesnetwork.com/give. If you prefer to donate by cash or check, please do so at the time of your appointment.

We are grateful for smaller gifts.

If this amount is a hardship, please let us know when you submit your intake form or email for follow up appointments. We do not want this suggested donation to prevent anyone from receiving ministry. We will gladly explore options and scholarships with you as you make your appointment.

We are also grateful for larger gifts.

A single prayer room appointment actually costs about $90. The healing that happens in these appointments is, of course, invaluable. Donations over and above $40 help us offer scholarships to those not able to afford a donation and help keep the prayer room doors open. The cost of prayer room ministry includes our prayer room hours with clients, scheduling and client communications, rent, office supplies, website support, accounting, training volunteers, payroll for three part-time staffers, and more.

Thank you for giving as you're able! *
Submit
Never submit passwords through Google Forms.
This form was created inside of Equipping Ministries International. Report Abuse - Terms of Service - Additional Terms