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One-Time Rachel's Well User
So glad to have you at Rachel's Well. This information helps us craft a meaningful experience for you and helps us track usage. The information will be shared only as needed with the assigned attendant and Mikvah Coordinator.
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Name
*
Your answer
Purpose of Visit
*
There are traditional & contemporary reasons for a mikvah immersion. Some are part of a celebration, others mark a life transition or a component of healing. Whatever the reason, Rachel's Well is here for you.
Choose
Conversion
Taharat Hamishpacha, Monthly Use
Bride or Groom
Bat or Bar Mitzvah
Birthday
Anniversary
Death and Mourning (eg., yartzheit, shloshim, etc)
Healing from Illness or trauma
Pregnancy loss / infertility struggles
Other
If you selected "other" please detail the reason for your immersion request.
Your answer
If coming for conversion, who is your sponsoring Rabbi?
Your answer
If completing form for child(ren)'s immersion, please give the name(s)
Your answer
Date of Birth of Immerser(s)
*
MM
/
DD
/
YYYY
Address/Country
Your answer
Email
*
Your answer
Cell Phone
*
Your answer
Gender
*
Female
Male
Other:
How did you hear about Rachel's Well?
*
Clergy
Congregational Communication (Email, Newsletter, Facebook Post, Website)
Federation Communication (Email, Facebook Post, Website)
Word of Mouth/Friend
Other:
Do you require a traditional (orthodox) attendant for your immersion?
*
Yes
No
If for Taharat Hamishpacha, date requested
MM
/
DD
/
YYYY
If other reason for immersion, date range requested.
Your answer
Thank you for completing this form. We will be in touch within 48 hours with your appointment time.
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