Pastoral Care and Support Form

Pastoral Care & Support Form

We are committed to helping people grow and flourish in every area of their lives by providing care and support through Small Groups and our Pastoral Care ministries. Please tell us just a bit more about you and your current need, so we can provide the best care and support possible.
Please note that in filling out this form you give us permission to share your information with appropriate staff members. All information will be otherwise kept confidential.
Your Name*

First NameLast Name
Your Email*
example@example.com
Your Phone Number*
Your Address*

Street Address

Street Address 2

CityState

Zip Code
Which area of Pastoral Care are you requesting?*
How long have you attended Visible?*

VC PartnerVisitorNever Atteded

Financial
What kind of assistance are you seeking?*

Benevolence
Please tell us more about your current situation:*
Are you currently employed?*

YesNo
If yes, where are you currently employed?*
Our Care & Support process to determine how we can best help you may take several days. If your circumstances require immediate action, we encourage you to contact your local government or other community agencies for assistance.

Funeral
Thank you for reaching out and we are so sorry to hear about your loss. Please click "Submit" below to submit your information and a member of our Care & Support team will reach out as soon as possible.

If there are any questions in the meantime, please don't hestiate to reach out to us directly.
Please list the date of the funeral and additional details needed.

Hospital Visit
Name of the person in Hospital:*
Name of the Hospital:*
Hospital Room Number*
Why is the person requesting a visit in the hospital? *
(Accident, procedure etc.)
What is the current status of the person requesting visit? *
(Critical, Stable etc.)

Parenting
Your Name*

First NameLast Name
Name of Parent/ Legal Guardian*

First NameLast Name
Relation to the Child*
Child's Name*

First NameLast Name
Child's Date of Birth*

MonthDayYear
Date
Child's Gender*

FemaleMale
Who does the child live with? *
(Parents, Step Parents, Grandparents, Siblings, etc.)
Does the child attend school?*

YesNo
If yes, what grade/ year?*

Parenting

(Page 2/3)
Tell us a little about your child. Does he/she have any interests or hobbies? What arehis/her positive characteristics?*
What is the primary reason for your concern?*
Does your child share your concerns? Why or why not?*
Is there a concern of abuse or a history of abuse, either physical, mental, emotional, sexual or other?*

YesNo
If yes, please explain.*

Pre-Marital Coaching
Thank you for your interest in Pre-Marital Coaching! Please click "Submit" below so we can receive your initial information.

If there are any questions in the meantime, please don't hestiate to reach out to us.
Wedding Date
Describe your relationship
Both Emails
example@example.com
What days and times during the week are best for you both to meet?*

Marriage Coaching
Please describe the current status of your Marriage:*
Are you experiencing physical abuses?*

YesNo
Are there any anger issues?*

YesNo
Are there any issues, which you feel may require professional mental health attention?*

YesNo
Are both you and your spouse willing to participate in marriage coaching?*

YesNo
Spouse's Name

First NameLast Name
Spouse's Email
example@example.com
Spouse's Phone Number
What days and times during the week are best for you both to meet?*

Counseling/ Coaching History
Have you received counseling/coaching before?*

YesNo
If yes, who facilitated the counseling/coaching?*
When did the coaching take place?*
What were the results?
By filling out this form and clicking "Submit" below, you give us permission to share your information with appropriate staff members. I recognize that all information will be otherwise kept confidential.*

I acknowledge the above
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Pastoral Care & Support Form