Anyone desiring pastoral care and counseling should complete the form below. This form will be used to help us determine if Restored Pastoral Care & Counseling is the best context for you to obtain help, and how we can best help you.

Please know that we value your privacy. This form is confidential and will only be seen by the elders and the pastoral care provider who will be seeing you.

Please be as detailed as possible. If your situation is urgent please contact your Gospel Community leader and/or pastor directly. If you are in an emergency situation, please call 911. 

Name: *
Phone Number: *
Phone Number:
Address: *
How would you prefer to be reached in response to this request?
Gender: *
Date of Birth: *
Date of Birth:
Emergency Contact Phone Number: *
Emergency Contact Phone Number:
Are you currently under the care of a psychologist, psychiatrist, or other mental health professional? *
Are you currently taking medication for your mental health? *
Are you currently in a Restored Uptown Gospel Community? *
Have you talked with your Gospel Community leader about this issue?
Have you talked with another pastor or church leader about this issue? *