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Lighthouse Diaconal Care Form

Are you asking for prayer and spiritual care? Fill out the Prayer Request Form

Is this being filled out by a deacon?

Is this being filled out by a deacon?

Name

Phone Number

Email

Address

Age

Sex

Sex

Spouse's Name

Childrens' Names and Ages

Family Members Living with You

Are you a member of Lighthouse Presbyterian Church?

Are you a member of Lighthouse Presbyterian Church?

Have you previously been assisted by the diaconate? How?

Do you currently receive financial assistance? What for?

Names and phone numbers of personal/pastoral references/Small Group Leader to be called for further info?

Current Situation/Request

What is the current problem?

How long has the problem been going on?

Other important details

What steps have you taken to remedy the situation?

What is your request of the Diaconate?

Is your request financial in nature or related to employment?

Is your request financial in nature or related to employment?

Education and Work History

Nature and duration of current employment

Work history

Highest level of education and degrees held

Other training certificates or programs completed

Spiritual Social and Emotional Health

Describe person’s Christian Experience/spiritual journey

What social supports does this person have?

Family living by?

Family living by?

Discipleship group?

Discipleship group?

1 or 2 close friends who know of the situation? Who?

Any family members person is close to? Who?

Is the person seeing a counselor? Who?

Has the person been diagnosed and/or treated for mental illness? Explain.

Is the person taking prescribed medications? Explain.

Has the person taken prescribed medications in the past? Explain

Has the person ever been hospitalized for depression/suicide or other mental illness? Explain

Financial Position

General Monthly Expenses

Current Monthly Salary

Other Financial Income ( Check all that apply and the monthly or total amount)

Savings

Pension

CPP

Securities

Unemployment

Public Assistance

Food Stamps

Other?

Do you have medical insurance?

Do you have medical insurance?

General Monthly Expenses

Rent

Utilities

Phone

Food

Transportation

Debt

Other

Housing Situation

Are you without a home?

Are you without a home?

Rent or Own?

Roommates?

Who do you live with?

Dependants living with you? Who?

Is this a temporary living situation?

Explain the temporary nature

What type of housing do you have?

What type of housing do you have?