Care Intake Form - Grace Community Church

Phone number *

How can we help? *

**Please note that if you select Benevolence, you will have to fill out an additional form so that we can try to assist.

Prayer

Wedding (Premarital Counseling)

Marriage Enrichment

Pastoral (Biblical) Counseling

Benevolence (Financial Assistance)

Visitation (Hospital or Home Visit)

Memorial/Funeral Service

How can we pray for you? *

Please select one of the visitation options: *

Home Visit

Hospital Visit

Hospice Visit

I understand that by requesting any Financial Assistance I will be required to fill out an additional form that will be emailed to the email address I provided. *

By accepting you understand we will not be able to follow up until we have received the completed Financial Assistance Request Form.

Who referred you to Care? *

Please include any additional details. *