The Community Rebirth Spiritual Mentorship Program Appointment Request Form
Let us know how we can help you!
Welcome
If you are seeking prayer, spiritual guidance, mentorship, or emotional support, you are in the right place. The Community Rebirth Spiritual Mentorship Program is confidential, non-denominational, and open to anyone who needs grounding, compassion, and community care.Please complete the form below so our team can match you with the right mentor, minister, or spiritual guide. DISCLAIMER: This form is not monitored 24/7. If you are experiencing a crisis or emergency, please contact 911 or a local crisis line
Full Name
*
First Name
Last Name
Contact Number
*
Please enter a valid phone number.
Email Address
*
example@example.com
What date and time work best for you?
Any other specific date and time, if the above selection is not suitable.
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Do you prefer virtual or in-person support?
*
Virtual
In-person (if available)
No preference
What services are you interested in?
*
Please Select
ONE -ON- ONE PRAYER
SPIRITUAL COUNSELING
ONGOING MENTORSHIP
What type of support are you requesting? (choose all that apply)
*
PRAYER
ONE-TIME SPIRITUAL SUPPORT SESSION
ONGOING MENTORSHIP (3-12 MONTHS)
SUPPORT DURING ILLNESS (EX: CANCER PATIENT/SURVIVOR/CAREGIVER)
PREGNANCY/POSTPARTUM SUPPORT
GRIEVING/LOSS
MENTAL/EMOTIONAL HEAVINESS
SPIRITUAL FATIGUE OR DISCONNECTION
MAJOR LIFE CHANGES OR IDENTITY SHIFTS
YOUTH MENTORSHIP
DO YOU PREFER A MALE OR FEMALE MENTOR?
MALE
FEMALE
NO PREFERENCE
Would you like us to pray with you during your first session?
YES
NO
MAYBE/UNSURE
Type option 4
Would you like to be added to our email list for encouragement and upcoming events/info?
Yes
No
Do you consider yourself part of any faith or spiritual tradition? (Single Choice)
*
Yes
No
It's complicated
I'm exploring
Prefer not to say
Confidentiality Acknowledgment: I understand that this program provides non-clinical, spiritual support. My sessions are confidential except in cases of safety concerns
*
I agree
Anything else that you would like for us to know?
Submit
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