First Time Rachel's Well User
In order  to provide you with the best immersion experience possible, we'll need to collect some information from you. Please note that information will be shared only as needed with the assigned guide and Mikvah Coordinator.
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Name *
Address *
Email *
Cell Phone *
Can you send and receive texts? *
Required
Home Phone (if applicable)
Date of Birth *
MM
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DD
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YYYY
Gender *
Synagogue Affiliation (If applicable)
Other Jewish Connections (memberships, classes, home-based practice, etc.) *
Is this your first immersion in a mikvah? *
How did you hear about Rachel's Well? *
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.
If you selected "other" please detail the reason for your immersion request.
Do you require a traditional (orthodox) attendant for your immersion? *
If for Taharat Hamishpacha, date requested
MM
/
DD
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YYYY
For all other immersions, please list date range and/or day/week and time(s) available for your immersion.
Weekday hours: 9:30am to 5pm; Weeknight hours (women only): ~7pm and beyond
Mikvah Preparation - Do you need to prepare at the Mikvah for your immersion? *
Some users bathe at home in preparation for their immersion. Others want/need to bathe at the mikvah. Either way, you will shower at the mikvah before your immersion. Your response will enable us to schedule an immersion time that will meet your preparation needs.
Will anyone be accompanying you to Rachel's Well? *
Would you like information on how to prepare for your visit? *
Are there any medical issues you'd like us to know about?
Are there any special requests, questions or additional information you would like to share?
Thank you for completing this form. We will be in touch within 48 hours with your appointment time.
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