Visitation Request Form

Are you in need of a pastoral visit? Would you like a lay member to visit you once a month or even on a weekly basis? Do you need communion? Fill out this confidential form which is sent directly to a pastor.

In the hospital? Bethel calls the hospitals three times a week, but occasionally, names are not reported to us or someone is not officially listed under Bethel’s name. A Bethel pastor would love to come see you, but please let them know!

Full Name of Person to Be Visited:*
Current Address and Phone Number*
Main Reason for Visit*
Name of Person Making This Request:
If you are making this request on behalf of someone else, we would like to know your name as well. Thank you for reaching out to Bethel so we can better care for those with specific needs.
Would you like communion?
- Yes
- No
- I'm Not Sure
Would you be interested in a Stephen Minister?
Trained lay persons can meet with those who are in extra need of care. They would visit weekly for about an hour.
Would you prefer a specific pastor?
Alternate Contact - Name, Contact Information, Relationship
Occasionally, the person in need of a visit is not able to speak, has moved to a different location, or there are other complications. An alternate contact helps us stay in touch.
Phone
This field is for validation purposes and should be left unchanged.