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My Portal : Celebration Church
ORL Care Request
Use this form to request care. Please read the "Agreement for Care Terms" prior to submitting this form.
*
First Name
*
Last Name
*
Email Address
*
Phone Number
*
I am Requesting Care For:
Myself
Couple Care (My Spouse has agreed to participate with me)
My Child
Other
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Name of Person 1 Needing Care:
*
Date of Birth (MMDDYYYY):
Name of Person 2 Needing Care:
Date of Birth for Person 2:
*
Type of Care Being Requested:
Consult With a Pastor or Care Partner
Learn About Professional Counseling
Hardship Assistance
Prayer
Other
*
Please provide additional details for your request:
Confirmation of Care:
Link to
Agreement for Care
. Please download and read.
*
Accept Terms:
I have read and ACCEPT the terms in the Agreement for Care
Terms for Another:
I have read/communicated terms to my Child/Spouse/Other if necessary
Decline Terms:
I DO NOT ACCEPT the terms of the Agreement for Care
Submit Form
