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Hospital or Facility Visit Request

Our church family is committed to walking with one another through every season of life, including times of illness, recovery, and extended care. If you or someone you know is currently in a hospital, rehabilitation center, nursing home, or care facility and would like a visit from a member of our pastoral or care team, please complete this form.

This request allows our team to pray for you, offer encouragement, and provide spiritual support during this time. Visits may include prayer, Scripture reading, or simply spending time offering comfort and fellowship.

Please provide as much information as possible so we can coordinate the visit appropriately and respect any facility guidelines.

All information submitted will be handled with care and discretion.

Your name *

Last name

Email address *

Your Information

Phone number

Phone type

Your relationship to the person needing the visit?

Information About the Person Being Visited

Full name of the patient *

Patient’s date of birth (optional but helpful)

Patient’s gender *

Is the patient a member of our church? *

Yes

Not Sure

Location & Logistics

Name of Hospital or Facility *

Hospital Address or City *

Room number (if known) and Unit/department (ICU, ER, Surgery, Rehab, etc.) *

Purpose of the Visit

What is the reason for the hospital or facility stay? (Brief description) *

Is the patient aware a visit is being requested? *

Yes

Any special instructions or restrictions? (e.g., limited visitation hours, isolation precautions, preferred time) *

When would you like the visit to take place? *

As soon as possible

Within 24 hours

Within the week

Specific date or time

If "Specific date or time" was selected, what date and time is requested?

Spiritual/Pastoral Needs

What type of support is needed? (Check all that apply) *

Prayer

Encouragaement

Communion

Anointing

Pastoral Care Conversation (Emotional support for medical diagnosis, prognosis, change in condition, etc.)

Other

Additional Notes

Please share anything else that our Pastoral Care team should know

A copy of your responses will be sent to your email address.

Trinity Harvest Church
info@thcconnects.com
8179523000

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