Congregational Care Request Form - Immanuel Anglican Church

Section 1 - Contact Information

Your relationship to Immanuel *

Member

Attendee

I have no formal relationship with Immanuel

Are you filling out this form for yourself or someone else? *

Myself

Someone else

Section 2 - Type of Support Needed

Check any that apply *

Prayer request

Hospitalization / Medication

Illness / Diagnosis

Pastoral Visit

Homebound Support

Meals (birth, surgery, crisis, etc.)

Financial Assistance

Counseling Referral

Grief / Bereavement

Family or Relationship Crisis

Job Loss / Financial Hardship

Care for Elderly Relative

Transportation Needs

Other

Section 3 - Details

Please describe the situation *

Is this urgent? *

Yes

No

Has a pastor or staff member already been in touch? *

Yes

No

Are you connected to a Neighborhood Group? *

Yes

No

Section 4 - Care Follow-Up

Would you like... *

A pastor to contact me

A care volunteer to follow up

Prayer support only

I'm sharing this for awareness, not follow-up

Section 5 - Permission

May we share this request with our confidential Care Team? *

Yes

No

May we share this request with the Prayer Team? *

Yes

No

Date of Submission *