Pastoral Care Request Form
Please complete the form as thoroughly as possible to request pastoral care for a member of our New Beginnings family.
What is your name? (Staff Member Completing the Form)
*
What type of Pastoral Care is being requested?
Hospital Visit
Bereavement Call
Nursing Home Visit
Other
Name of the person in need of a pastoral care:
*
First Name
Last Name
Phone number of the person in need of pastoral care:
Please enter a valid phone number.
Format: (000) 000-0000.
What is the name of the Nursing Home?
What is the address of the nursing home?
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home address of the member who lost their loved one:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Has the person in need of a visit given consent to have a representative of the church visit them?
*
Yes
No
Who should be contacted if the person in need of a visit cannot answer? Please list their name and phone number.
(Ex: Jane Doe - 903-111-2222)
Please provide the following information: hospital or medical facility name; room number; date and time for admittance/ procedure; information about the person's condition and/ or procedure; etc.
*
EX: Good Shepherd - Room W322 - 4/24/2000 - 10am - John Doe has been admitted for heart complications.
Which campus does the person in need of a visit attend?
*
Longview
Gilmer
Español
Online
Does not attend New Beginnings
Please choose any of the ministries that the person in need of a visit is connected to?
New Baby
Pre-School
K-5th Grade
Jr. High (6th-8th Grade)
High School (9th-12th Grade)
College
Worship Team
Welcome Team
Deacon
Soul Care Group
Other
Do they attend a Life Group?
Yes
No
Which Life Group are they in?
Is there any other pertinent information that would aid our church in caring well for the person in need of a visit?
Please provide any details that will help our staff care well for the person in need.
Submit
Should be Empty: