Care Request Form 2024

Counseling Referral
What type of counseling referral are you requesting?
Is the contact information the same as listed above?

YesNo
Name

First NameLast Name
Email
example@example.com
Phone Number

Area CodePhone Number
Please describe your need
Are you open to receiving a professional mental health referral?

YesI want to learn moreNo
Are both you and your fiancé or spouse willing to participate in counseling?

YesNo
Fiancé or Spouses' Name
Fiancé or Spouses' Email
example@example.com
Fiancé or Spouses' Phone Number

Area CodePhone Number
What days and times of the week work best for you to meet?

Emergency
What type of emergency is this?
Name of the individual in the Hospital/Hospice
Name of the Hospital
Hospital room number
Why is the individual in the Hospital?
Current status of the individual in the Hospital
Hospital/Home address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of the deceased individual
Other family members or disciples related to the deceased
Please explain your current situation and the assistance you are requesting
Are you a Central Disciple?

YesNo
Is the contact information the same as listed above?

YesNo
Your full name

First NameLast Name
Your phone number

Area CodePhone Number
Thank you for reaching out. We extend our deepest condolences about the death of your loved one.

You may stop here, please click "Submit" below and we will reach out as soon as possible.

If there are any questions in the meantime, please don't hestiate to call the church office.
Thank you for reaching out. Someone from our benevolence team (emergency assistance) will be contacting you within the next 48 to 72 hours. You may stop here, please click "Submit" on the next slide and we will reach out as soon as possible.

If there are any questions in the meantime, please don't hestiate to call the church office.

Central Cares!