Care Form - James River Church

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NEEDHELP

INPERSON

CONTACT

REF

We Would Love to Connect With You!

Contact Us

In-Person Info

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

Filling out for myself
Filling out for someone else

IP_ADDRESS

Which campus are you attending?*

South
West
North
Joplin

Your Details

Your Name*

First Last

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Date of Birth*

Other Details

Gender*

Male
Female

Phone*

By providing your phone number, you agree to receive texts from James River Church. Messaging and data rates may apply, message amounts vary.

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Person Information

Email*

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Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Birthday*

Marital Status

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Marital Status*

Married
Widowed
Divorced
Single

Spouse's Name*

First Last

Spouse's Date of Birth*

Spouse's Gender*

Male
Female

What James River Campus do you attend?*

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Care Details

Individual's Details

What is the name of the member needing care?*

First Last

Their Phone Number*

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Do you have a church home?*

Yes
No
I am looking for a church home

Do you attend JRC?

Yes
No

I attend*

James River Church
Other

Which Campus*

How Long Have You Been Attending?

Additional Information/How Can We Help You

I Would Like More Info About:

Life Groups
Freedom Groups
Soul Set Free Groups
Joining a Dream Team (Volunteering)
Counseling - Biblical Guidance
Becoming a Christian / Getting Baptized
I Have a Question

Please Share Your Question*

Counseling:

Pre Marital
Marital
Parenting
Finance
Grief
Marriage 911
Other

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Need Help

Please Note: If this is an urgent matter, please call the church office at 417-581-5433.

Reason Requesting Care*

Please identify the reason you are requesting care.

Please select the type of celebration*

Please select the type of medical need*

Please select the type of bereavement*

Please select the type of disaster*

Please select the type of family/marriage need*

What emotional symptoms have you or this individual been experiencing?*

Reason financial support is needed*

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Life Event/Hospitalization:

I Am Currently In The Hospital
I Have An Upcoming Surgery
Birth of Baby
Death in Family
Emergency Situation
Other

Prayer Request

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Marriage

Please Provide:
- First & Last Name of the Couple
- Date of Marriage
- Couples Mailing Address

Marriage*

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Birth

Please Provide:
- First & Last Name of the Parents
- Date of Birth
- Child's Gender
- Family's Mailing Address

Birth*

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New Foster / Adopted Child

Please Provide:
- First & Last Name of the Parents
- Date of Adoption/Foster
- Child's Gender
- Childs Age
- Family's Mailing Address

New Foster / Adopted Child*

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Recent Surgery

Please Provide:
- Type of Surgery
- Back at home or still in the hospital?
- Would this individual like for us to send them a recovery meal or flowers?
- Home or Hospital Address (If the individual is still in the hospital, please include the room number.)

Recent Surgery*

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Upcoming Surgery

Please Provide:
- Type of Surgery
- Inpatient or Outpatient
- Date and Time of Surgery
- Would this individual like for us to send them a recovery meal or flowers?
- Hospital Address

Upcoming Surgery*

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Hospitalization

Please Provide:
- The reason this individual is hospitalized
- Is this individual aware of this visitation request?
- Hospital Name & Room Number
- What are the hours of visitation?
- Are we allowed to bring flowers?

Hospitalization*

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New Medical Diagnosis

Please Provide:
- Name of the diagnosis
- How can we support you or this individual?

New Medical Diagnosis*

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Loss

Please Provide:
- If other, please explain below
- Name of Deceased
- Relationship to the Deceased
- Spouse of the Deceased
- Please let us know how we can support you or this individual's family during this time.
- Would you like for us to send flowers? If so, please provide a name and best mailing address below.

Loss*

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Disaster

Please Provide:
- If other, please explain below
- Details of the incident.
- How can we support you or this individual or family during this time?

Disaster*

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Family/Marriage

IMPORTANT: If this is a life threatening emergency, please dial 911.

Please Provide:
- Explain the situation and how we can help.

Family/Marriage*

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Mental Support

IMPORTANT: If this is a life threatening emergency, please dial 911.

Please Provide:
- A brief explanation
- Are you or this individual ready to speak to someone?

Mental Support*

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Financial Need

Please Provide:
- If other, please explain below
- Please explain how we can help you or this individual

Financial Need*

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Other

Other*

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Section Break

I Would Like To Share...*

Praise Report
Prayer Request

Would You Like For Someone To Call And Pray With You?*

Yes
No

Please Share Your Prayer Request*

Praise Report

Please Share Your Praise Report*

Life Groups

To get connected to a Life Group, click here!

Recent Hospitalization

Date of Hospitalization*

Hospital Location*

Circumstance of Hospitalization*

Upcoming Surgery

Date of Surgery*

Hospital Location*

Type of Surgery*

Other

If you need immediate assistance please call the church at 417-581-5433.

Please Give Us Details*

Counseling

Our approach to counseling is to use the Bible to address issues in the lives of individuals, couples, and families.

Please Tell Us A Little Bit About Your Situation.*

Pre-Marital Counseling

Fiancé's Name*

First Last

Fiancé's Gender*

Male
Female

Fiancé's Date of Birth*

Fiancé's Phone Number*

Fiancé's Email*

Fiancé's Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

How long have you been engaged?*

How long had you been dating prior to the engagement?*

When are you getting married?*

Is this your First or Second marriage?

First
Second

Please Tell Us a Little Bit About Your Situation*

Question

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Comments

James River Care Request

We Would Love to Connect With You!

Contact Us

In-Person Info

Your Details

Your Details

Other Details

Person Information

Care Details

Individual's Details

Additional Information/How Can We Help You

Need Help

Prayer Request

Marriage

Marriage

Birth

Birth

New Foster / Adopted Child

New Foster / Adopted Child

Recent Surgery

Recent Surgery

Upcoming Surgery

Upcoming Surgery

Hospitalization

Hospitalization

New Medical Diagnosis

New Medical Diagnosis

Loss

Disaster

Family/Marriage

Mental Support

Financial Need

Other

Section Break

Praise Report

Life Groups

To get connected to a Life Group, click here!

Recent Hospitalization

Upcoming Surgery

Other

Counseling

Pre-Marital Counseling

Question

Get Involved

About Us

Ministries

More