intake-form | Yulander Taylor

First name

Last name

Email

Phone

Address

Primary Contact Name and Position

Primary Contact Number

Primary Contact Email

Which type of organization is requesting assistance?

Explain Other

Brief Ministerial Care Description:

Requesting Date

Month

Day

Year

Requesting Time

Time

HoursMinutes

Ministerial Care Option

Care Circle Group

Chaplaincy & Comfort Care

Ministerial Wellness Mentorship

Number of Attendees

1-5

6-12

25 or more

In-Person or Virtual

Facility and Full Address

How can Ministerial Care Services assist you or your team?

Learning healthy boundaries to prevent compassion fatigue

Finding a safe, confidential space to voice and navigate through trials and conflict related to the organization.

Receiving bedside prayer, scripture reading, communion, encouragement and care support

Structuring a sustainable health and wellness strategy for my organization.

Are there any specific requests you would like us to hold in confidence?

DISCLAIMER & CONFIDENTIALITY AGREEMENT: All personal, health, and spiritual information shared on this form will be kept strictly confidential within Ministerial Care Services and handled with divine integrity. Scope of Services & Medical

Signature

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Date

Month

Day

Year

Thank you for submitting your request. We appreciate the opportunity to serve you. To ensure every request receives the attention it deserves, please allow 3–4 business days for a response via phone call or email. Business Operations M–F 9am-4pm CST

Blooming Leaf

Integrating traditional medicine and holistic wellness