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Care Assistance Application

Centerpoint Church wants to provide support, encouragement, and care for those facing various needs within our Centerpoint Gathering and community. Please complete this form so we have all relevant information and can make the best decision about how we can best help.

Once we receive this form our staff will contact you about how we may offer assistance.

Please note our primary method of assistance is to inform and refer individuals to our partners.

Centerpoint Staff keeps all records of requests and disbursement of assistance confidential.

Your name *

Last name

Email address *

Phone number *

Phone type

Relationship to Centerpoint Church *

Regular attendee

Visitor

Digital (online) attendee

Unfiltered Radio

Other

What is the nature of your need? *

Please check all that apply

Financial

Physical

Emotional/psychological

Financial assistance for counseling

Hurricane relief

Other

Please provide a brief summary of how we can help *

Please describe your need or request.

Are you in a community group? *

Are you currently on a volunteer team? *

If yes, please explain which team.

What steps are you currently taking to meet this need? *

For those requesting financial assistance (counseling or otherwise).

What is the total financial need?

Please list all needs and the specific amount for each.

How many individuals are currently living in your home?

What is your household annual income?

Have you applied for any financial assistance from the government or other agencies?

Is there a date you need this need met by?

For those applying for financial assistance for counseling: Does your medical insurance cover counseling services?

For those requesting financial assistance for counseling through the Chamberlain-Garland Fund

For those applying for financial assistance for counseling: If yes, what is your financial responsibility after insurance?

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Centerpoint Church
info@centerpointfl.org
813-689-1906

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