Name *

First Name

Last Name

Would you like to be contacted directly about this request? *

Yes

No

Are you in need of professional services (counseling, medical, financial, etc.)?

Yes

No

Unsure

Do you attend York Wesleyan Church?

Yes

No

Occasionally

Is your request time sensitive? (i.e. doctor's appointment, or procedure)

MM

DD

YYYY

By submitting this form, I understand that my request will be viewed by pastoral staff and website admins. While we are good stewards with the information you share and will uphold to confidentiality of this form, your safety and the safety of your family is our priority. If you, or someone you know is at risk for suicide, abuse, or the loss of life, please call 911 or visit our resource page for the appropriate contacts. If you're unsure if you're in need of such services, we have mandatory reporters and licensed counselors on staff to help walk and guide you. *

I understand