Care Request Form

First Name

This address will receive a confirmation email

Introductory Statement of Care Acknowledgement

***PLEASE READ THIS STATEMENT BEFORE FILLING OUT FORM***

If you are not a member or a regular attender of Citylight Council Bluffs we would always recommend that you reach out to your local church and pastors to seek care and counsel. We do not offer care to people who attend other churches because we believe it is the call of your church leaders to shepherd and care for you.

Please keep in mind that we are not a counseling center and that we have a small team of people who have availability to offer care, so know that we do refer people to care at counseling centers outside of the church if we feel like the best and most appropriate care can come from an outside counselor.

After filling out the Care Request Form we will seek to connect with you via email within 7 days to set up an initial meeting. Please keep in mind that an initial meeting is not a long-term commitment to care, but is a tool that we use to hear about you and the present situations and struggles that you are experiencing. We take what we learn in the initial meeting to offer a plan or next steps of care that we believe will be the best and most appropriate care for you at this time.

Before filling out this Care Request Form, I have read and acknowledge the above statement.

Personal Information and Contact Info

Phone

Phone Type

Gender

Birthday

Marital Status

Tell us about your Citylight involvement.

How long have you attended Citylight?

How are you currently involved in the life and community of Citylight? Do you attend on Sundays mornings only? Do you serve in the church and, if so, where do you serve? How are you involved in the life of the church?

Are you currently in a City Group?

Which City Group are you involved in? (If you're not involved, type "none".)

How have you communicated to others in your City Group, your City Group leaders, your Huddle, or your community of friends about the issues or struggles that you are seeking care for?

Reason for Care

What type of care are you seeking?

In a few sentences, please explain why you are seeking care at Citylight. What are the present issues or struggles that you are facing?

In a few sentences, please explain how your past struggles, difficulties, addictions, and/or sin patterns have affected your present circumstances and struggles?

Have you previously sought or received care for any of these past or present circumstances or struggles? If so, please explain the care that you received: who was it with? when was it? why did you stop?

Is there any other information that you want to share with us?

Acknowledgments

Our primary method of making contact with you to talk about setting up an initial appointment will be through email. Did you enter an email address that you check regularly? (If you have not heard from us within 7 days, be sure and check your spam or junk folder.)

I give permission to share this information with the appropriate ministry leaders and/or care team member to arrange for an initial meeting.

I understand and acknowledge that an initial appointment for care is not an ongoing commitment to care at Citylight.

I acknowledge that I filled out this Care Request Form to seek care for myself. If I am requesting care for my marriage, I acknowledge that my spouse knows I am filling out this form to request care for us. I am not filling out this form for another person to request care for them.

Care Request Form

Description

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