Request a Pastoral Care Team Visit

If you would like to request a Pastoral Care Team Visit, please complete this form.

Pastoral Care Team Visits can be for upcoming medical procedures, unexpected hospital stays or just prayer and fellowship!

(Pastoral Care Team Visits will be completed by any person on the care team such as Pastor Mark Heffinger, Pastor Rick Houghton, Pastor Belinda Miles, or another assigned designee. )

Your name *

Last name

Email address *

Gender

Phone number

Phone type

Address

Country

Street Address

Apt/unit/box (optional)

City

State

Postal code

Who is the person filling out this form? *

Self, family member, friend etc. If you are filling this out on behalf of someone else, please include your NAME & PHONE NUMBER.

Who is the visit for? *

Self, family member, friend etc. Please include the persons name.

What is the persons phone number? (person we are visiting) *

Reason for visit? *

Hospital visit.

Home visit

Prayer

Fellowship

Other

Do you have an upcoming medical procedure? *

If this is for an upcoming scheduled medical procedure, please be sure to fill out the next question with the date and location of the procedure.

Yes

Date for upcoming procedure:

Location for upcoming procedure:

Please include the name of the facility and address.

Are you currently in the hospital and requesting a Pastoral visit? *

If you are currently in the hospital, please complete the next box and let us know which hospital you are in and the anticipated discharge date if known.

Yes

Which hospital are you located at?

What is your expected discharge date (if known)?

What type of visit would you be most comfortable with? *

If so, please fill out the next box and let us know which days you are available.

Home Visit

Visit at Neutral Location (Church, Coffee Shop, Restaurant, etc.)

Video Chat

Phone Call

Other

Which days are best for a Pastoral visit? *

Please select all options. We will do our best to accommodate your schedule.

Monday

Tuesday

Wednesday

Thursday

Friday

Do you have a preference on who preforms your visit? *

No Preference

Pastor Mark Heffinger

Pastor Rick Houghton

Pastor Belinda Miles

Any addition information we should know?

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