Heaven On Earth Request For Healing Ministry
Please complete this application as the first step to obtaining an appointment for the healing prayer ministry.
After completing the contact information, you will be asked to sign a release of liability form on the back of this
application. Ministry appointments cannot be granted to anyone who refuses to sign this form. Email, mail or drop this
form off to Sandy in the church office. Website available also on St. John XXIII, Fort Collins-- www.john23.com
Your name will be added to a waiting list. You will be contacted by email or phone for available times. Your information
will be kept confidential by the administrator and administrative staff overseeing this ministry. A copy of your application
will be given to the leader of the healing team you are assigned to. This is for purposes of prayer and preparation of the
ministry team.
If you feel you are in need of immediate ministry attention, you should contact your pastor of your parish.
The Heaven on Earth Healing Ministry does not provide home visitation, family or personal intervention or crisis ministry.
This ministry depends upon trained and equipped volunteers and will strive to coordinate appointments around their
availability. You will be asked to indicate the best times of the day and week that you are available for ministry. We will
do our best to serve you accordingly. Donations to help support the ministry are highly appreciated. Cash or Checks will
be accepted. NO CREDIT CARDS OR DEBITS CARDS ACCEPTED.
Failure to keep an assigned appointment will result in loss of priority in scheduling a new appointment. If for any reason
you will not be able to keep your appointment, you must make every effort to call St. John @ 970-484-3356,
24 hours PRIOR to your appointment to let us know you must cancel and reschedule.
Do you request a specific leader for your healing session? If so, who? ______________________
NAME: ___________________________________
GENDER: M___ F___
DATE: ______________
ADDRESS (no PO Box #’s please) __________________________________________________________
CITY: _________________________________ STATE: _______ ZIP: ________BIRTH DATE___________
Email: ___________________________________
Home/Day Phone: _______________________
Personal Cell: _____________________________
Other phone: ___________________________
My need for ministry concerns:
Physical Healing
Inner Healing
Deliverance
Emotional Issues
Other (Please explain) _____________________________________________________
_____________________________________________________________________________________
Are you currently taking anti-anxiety medication? Yes or No Are you currently or have you been in the past
under the care of a professional psychologist? If so explain_________________________________
Are you currently grieving the loss of a significant relationship or job?
Are you fully initiated in the Catholic Church? Yes
Yes
No
No
Which sacraments have you completed? ___________________________________________________
Have you been baptized in the Holy Spirit?
Yes
No
Not Sure
I am now attending _______________________ as my church home.
Please note the day of the week and time of day you are available for ministry: ____________________
How did you hear about Heaven On Earth Inner Healing Ministry?________________________________
**PLEASE COMPLETE REVERSE SIDE OF THIS FORM**
Release of Liability
This form must be signed prior to being assigned any ministry appointment.
I, the undersigned, do hereby release St.John XXIII and any of its staff, leaders and volunteers, from
any harm or perceived harm resulting from my voluntary receiving of free prayer on this and
subsequent visits. I understand that this pastoral care ministry is provided by a staff of volunteers
representing the body of Jesus Christ. They are not trained or licensed medical professionals, or
psychological counselors, or therapists, and they do not provide medical or psychological services. I
acknowledge that I need to seek advice from my medical doctor, therapist, counselor or other
professionals to confirm any results of prayer received before altering any prescribed course of
action. I understand that this form and all data recorded on it is the sole property of St.John XXIII. All
content will be held in confidence for the sole purpose of the ministry unless I have given permission
for such things to be shared.
Signed _______________________________________________ Date___________________
(YOU MUST BE 18 OR OLDER TO BE ELIGIBLE FOR THIS MINISTRY)
Parent or Legal Guardian Name: _______________________________________________
Signature of Parent or Legal Guardian: __________________________________________
Witness: (leader of session signature)________________________________________ Date: _____________
Donations
Please consider making a love donation to the ministry. We ask that you pray about making a donation to the
healing ministry to help us in the expenses, development and growth of this ministry. The average donation is
$55.00 per session. Our healing volunteers make great personal sacrifices to help you find freedom in Christ.
We will minister to you whether you give or not. IMPORTANT: Cash is accepted or checks can be made out to
the leader of the session. If you choose to donate more than the suggested amount, please pay the leader the
donation suggested and then write a separate check out to St. John 23, put in the memo line: Heaven On Earth
Ministries. WE DON’T ACCEPT DEBIT OR CREDIT CARDS.
Confession
It is recommended that Catholics try to go to confession prior to this session. It is not mandatory but can
aide in healing.