Gateway Care is here to provide ministry and assistance to individuals and families that call Gateway Church home. Gateway desires to come walk beside you if you are struggling with sickness or disease, in the midst of the passing of a loved one, needing individual, pre-marriage, marriage or family counsel from a Christ-centered perspective. If you desire Gateway’s presence with you in any of these physical, spiritual, emotional, relational or financial situations – please fill out our Ministry Questionnaire. Once this is submitted, someone from the Care Team at your campus will respond to your request.

* indicates information required. 

Note: To provide the best support, we ask each person receiving care to attend one of our campuses in person. Also, if you are seeking marriage or couples counseling, each person must complete this form. 

Thank you!

Date*
Name*
Date of Birth*
Gender*
Address*
NOTE - If you are seeking Marriage or Couples Counseling, each individual must submit a questionnaire.
Have you become a member of Gateway Church by taking session 1 of Growth Path?*
Have you previously become a member of Gateway Church by attending Catch the Vision?*
Do you attend a Gateway Group?*
Spouse's Name
Spouse's Date of Birth
Do you have children?*
Fiancé's Name
Fiancé's Date of Birth

Reason for Seeking Ministry

What type of ministry are you reaching out for?*
What is the name of your loved one?*
What was your release date?*

Reason for Seeking Ministry

What type of ministry are you reaching out for?*
Did anyone refer you for ministry?
Do you prefer morning or afternoon appointments?
Have you ever struggled with the following?*
Have you ever struggled with the following?
  Current Past No
Feelings of Inferiority
Suicidal Thoughts
Suicidal Attempts
Angry Thoughts
Rejection
Unforgiveness
Family History of Mental Illness
Angry Outbursts
Eating Disorders
Lustful Thoughts
Depression
Excessive Anxiety of Worry
Excessive Fear
Spiritual Abuse
Physical Abuse
Verbal Abuse
Emotional Abuse
Sexual Abuse
Sexual Addiction
Substance Abuse/Addiction
Gambling Addiction
Under Too Much pressure/Feeling Stressed
Nightmares
Feeling Trapped in Rooms/Buildings
Obsessive Thoughts
Suspicious Feelings Towards Others
Feeling Numb or Cut Off From Emotions
Blackouts or Temporary Loss of Memory
Concerns About Emotional Stability
Sleep Difficulty - Not Enough or Too Much
Loss of Appetite or Increased Appetite
Overeating then Vomiting to Control Weight
Excessive Use of Alcohol
Abuse of Prescription Drugs
Getting into Trouble at Work/School
Not Being Able to Say What You Really Think or Feel
Feelings as if You Would be Better Off Dead
Feeling Manipulated of Controlled by Others
Difficulty Making Decisions
Loss of Interest in Sexual Relationships
Feeling Sexually Attracted to Members of Your Own Sex
Compulsive Behavior
Inability to Concentrate at School or Work
Loss of Interest in Usual Activities/Lack of Motivation
Crying Spells
Inability to Control Thoughts
Feeling Like You are Being Watched
Hearing Voices

Hospitalization

Who is the best point of contact?

Bereavement

Who is the best point of contact?

Spiritual Walk

Please Check All That Apply:*

Financial Help (Benevolence)

Your family and the financial distress you are feeling is very important to us. I would like to share Pastor Robert’s heart for Benevolence Ministry.


First and foremost, we are here to serve the active members of the Gateway Church Family, this involves having attended our Growth Path class and joining the church by affirming your beliefs with our beliefs and the vision of Pastor Robert for Gateway Church.


Our benevolence ministry serves those who have exhausted their current financial resources, have no local family support, and act as a short-term financial bridge for those who are pursuing a lifestyle below their income.


Some things that we have been able to help people with in the past include:

• Water

• Electricity

• Connections to a food bank or clothing center

• Small automobile gas cards

• And on rare occasions, one month of rent


Some of the things that we are not designed to assist with include:

• Medical bills

• Debts (credit card payments & loans)

• Past due rent & mortgage payments

• Legal expenses

• Cable


Benevolence ministry is not designed for on-going assistance, in most cases we provide one – time financial assistance during periods of unexpected hardships, followed by a next steps plan for long-term health.

Our Benevolence process includes the following steps:

1. Completing a Benevolence application

2. Meeting with a staff member to discuss your situation (Appointments usually last 45 mins. – 1 hour)

3. Ministry team reviews the application - All decisions are made by a team, and cannot be made or changed by an individual

4. Last you receive an email letting you know your next steps plan and letting you know if you have been chosen to receive assistance


Our multi-step process takes 2-3 weeks to complete, usually 3 weeks. Going through the benevolence process does not guarantee you will get monetary assistance.

Living in:*
Do you regularly tithe at Gateway Church?*
Have you previously requested financial assistance from Gateway Church?*
Please check all concerns that apply:*
Are you currently behind on paying any of your bills?*
Have you experienced eviction in the last year?*
Do you currently have and use a personal budget?*
$

*Please keep in mind that we usually assist with a one-time amount between $200-$750.

Is your family aware of your current situation?*

Please use the questions below to tell us about your monthly income sources and the net amount (after taxes and deductions) that you receive. Please note that income sources include all forms of monetary and non-cash increases, which include income from an employer, social support, SNAP, SSI/SSDI, VA, etc... 

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Do you have another source of monthly income? 1*
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Do you have another source of monthly income? 2
$
Do you have another source of monthly income? 3
$
Do you have another source of monthly income? 4
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Please answer the follow questions with how much you spend in each category each month. If you do not have a specific expense, please put a 0. 


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Adoption Grant Application

We love that the Lord is speaking to you and that you are interested in adopting! Please fill out the Adoption Grant application so we can find out more about what the Lord is calling you to do. We are so grateful for your heart to serve and care for vulnerable children. If you have any questions, please reach out to your campus Care Team. 

What type of adoption are your pursuing?*
$
$

Adoption Grant Application - Financial Information

Do you regularly tithe at Gateway Church?*
Have you previously requested financial assistance from Gateway Church?*
Are you currently behind on paying any of your bills?
Have you experienced eviction in the last year?
Do you currently have and use a personal budget?
$

Please use the questions below to tell us about your monthly income sources and the net amount (after taxes and deductions) that you receive. Please note that income sources include all forms of monetary and non-cash increases, which include income from an employer, social support, SNAP, SSI/SSDI, VA, etc... 

$
Do you have another source of monthly income? 1*
$
Do you have another source of monthly income? 2
$
Do you have another source of monthly income? 3
$
Do you have another source of monthly income? 4
$
$

Please answer the follow questions with how much you spend in each category each month.


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Do you have any debt? *

Adoption Grant - Required Documents

Please attach copies of the past two months of income statements for the household. *
No File Chosen
File uploads may not work on some mobile devices.
Please note this includes, but is not limited to, employment pay stubs, SSI/SSDI, Child Support, SNAP, and TANF.
Please attach copies of the past two months of income statements for the household.
No File Chosen
File uploads may not work on some mobile devices.
Please note this includes, but is not limited to, employment pay stubs, SSI/SSDI, Child Support, SNAP, and TANF.
Please attach copies of the past two months of financial statements for the household. *
No File Chosen
File uploads may not work on some mobile devices.
Please include all pages. Please note that financial statements includes, but is not limited to, checking account, savings account, and retirement plans.
Please attach copies of the past two months of financial statements for the household.
No File Chosen
File uploads may not work on some mobile devices.
Please include all pages. Please note that financial statements includes, but is not limited to, checking account, savings account, and retirement plans.
Please attach copies of any documents from your adoption agency you feel may be relevant to your application.
No File Chosen
File uploads may not work on some mobile devices.
Please use this space to update any additional documents you have.
No File Chosen
File uploads may not work on some mobile devices.

Adoption Grant Application

We love that the Lord is speaking to you and that you are interested in adopting! Please fill out the Adoption Grant application so we can find out more about what the Lord is calling you to do. We are so grateful for your heart to serve and care for vulnerable children. If you have any questions, please reach out to your campus Care Team. 

What type of adoption are your pursuing?*
$
$

Adoption Grant Application - Financial Information

Do you regularly tithe at Gateway Church?*
Have you previously requested financial assistance from Gateway Church?*
Are you currently behind on paying any of your bills?
Have you experienced eviction in the last year?
Do you currently have and use a personal budget?
$

Please use the questions below to tell us about your monthly income sources and the net amount (after taxes and deductions) that you receive. Please note that income sources include all forms of monetary and non-cash increases, which include income from an employer, social support, SNAP, SSI/SSDI, VA, etc... 

$
Do you have another source of monthly income? 1*
$
Do you have another source of monthly income? 2
$
Do you have another source of monthly income? 3
$
Do you have another source of monthly income? 4
$
$

Please answer the follow questions with how much you spend in each category each month.


$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
Do you have any debt? *

Adoption Grant - Required Documents

Please attach copies of the past two months of income statements for the household. *
No File Chosen
File uploads may not work on some mobile devices.
Please note this includes, but is not limited to, employment pay stubs, SSI/SSDI, Child Support, SNAP, and TANF.
Please attach copies of the past two months of income statements for the household.
No File Chosen
File uploads may not work on some mobile devices.
Please note this includes, but is not limited to, employment pay stubs, SSI/SSDI, Child Support, SNAP, and TANF.
Please attach copies of the past two months of financial statements for the household. *
No File Chosen
File uploads may not work on some mobile devices.
Please include all pages. Please note that financial statements includes, but is not limited to, checking account, savings account, and retirement plans.
Please attach copies of the past two months of financial statements for the household.
No File Chosen
File uploads may not work on some mobile devices.
Please include all pages. Please note that financial statements includes, but is not limited to, checking account, savings account, and retirement plans.
Please attach copies of any documents from your adoption agency you feel may be relevant to your application.
No File Chosen
File uploads may not work on some mobile devices.
Please use this space to update any additional documents you have.
No File Chosen
File uploads may not work on some mobile devices.

Wedding Information

*** Please allow up to three months for  premarital counseling through SYMBIS (Save Your Marriage Before It Starts) as the program is a 6-8 week commitment and subject to Mentor availability. 

Wedding Date & Time:*
:  
Are your requesting a Gateway Venue and/or Pastor?*
Have you contacted, weddings@gatewaypeople.com?
Are you currently living together?*
Are you abstaining from premarital sex? *

Required Application Documents

Please attach copies of the past two months of income statements for the household. *
No File Chosen
File uploads may not work on some mobile devices.
Please note this includes, but is not limited to, employment pay stubs, SSI/SSDI, Child Support, SNAP, and TANF.
Please attach copies of the past two months of income statements for the household.
No File Chosen
File uploads may not work on some mobile devices.
Please note this includes, but is not limited to, employment pay stubs, SSI/SSDI, Child Support, SNAP, and TANF.
Please attach copies of the past two months of financial statements for the household.*
No File Chosen
File uploads may not work on some mobile devices.
Please include all pages. Please note that financial statements includes, but is not limited to, checking account, savings account, and retirement plans.
Please attach copies of the past two months of financial statements for the household.
No File Chosen
File uploads may not work on some mobile devices.
Please include all pages. Please note that financial statements includes, but is not limited to, checking account, savings account, and retirement plans.
Please attach a copy of the bill (all pages) for which you are requesting assistance. Rent assistance requires a copy of the complete lease with the signature page. *
No File Chosen
File uploads may not work on some mobile devices.
Please note all bills that are submitted must be in the member's name. If the bill is approved, the payment will be made directly to the service provider.
Please attach a copy of the bill (all pages) for which you are requesting assistance. Rent assistance requires a copy of the complete lease with the signature page.
No File Chosen
File uploads may not work on some mobile devices.
Please note all bills that are submitted must be in the member's name. If the bill is approved, the payment will be made directly to the service provider.

Please use the below spaces for any additional documentation to complete your application.

Please use this space to update any additional documents you have.
No File Chosen
File uploads may not work on some mobile devices.
Please note all bills that are submitted must be in the member's name. If the bill is approved, the payment will be made directly to the service provider.
Please use this space to update any additional documents you have.
No File Chosen
File uploads may not work on some mobile devices.
Please note all bills that are submitted must be in the member's name. If the bill is approved, the payment will be made directly to the service provider.
Please use this space to update any additional documents you have.
No File Chosen
File uploads may not work on some mobile devices.
Please note all bills that are submitted must be in the member's name. If the bill is approved, the payment will be made directly to the service provider.
Please use this space to update any additional documents you have.
No File Chosen
File uploads may not work on some mobile devices.
Please note all bills that are submitted must be in the member's name. If the bill is approved, the payment will be made directly to the service provider.
Please use this space to update any additional documents you have.
No File Chosen
File uploads may not work on some mobile devices.
Please note all bills that are submitted must be in the member's name. If the bill is approved, the payment will be made directly to the service provider.
Please use this space to update any additional documents you have.
No File Chosen
File uploads may not work on some mobile devices.
Please note all bills that are submitted must be in the member's name. If the bill is approved, the payment will be made directly to the service provider.
Please use this space to update any additional documents you have.
No File Chosen
File uploads may not work on some mobile devices.
Please note all bills that are submitted must be in the member's name. If the bill is approved, the payment will be made directly to the service provider.

Physical Health

How would you rate your overall physical health?*
Have you ever had a life threatening or chronic illness?*

Emergency Contact Information

Gateway Church Ministry - Rights and Responsibilities

METHOD OF TREATMENT

Biblical (also known as pastoral or ministerial) counseling methods are brief and will focus on solutions through biblical principles. It is the role of the biblical counselor to help the member understand the dynamics of their situation, the power of God in their lives, and to assist them in using their particular strengths to address these issues.

Regarding the nature of biblical counseling: As you talk about your thoughts, feelings, and experiences, we will work together as partners to gain the understanding and insight necessary for change to occur. As a Christian, the Bible and the Holy Spirit are our guides. Any goals for counseling and/or decisions you make to facilitate change are ultimately up to you.

This is a church-based ministry of Gateway Church providing biblical counsel and prayer in individual and group settings. Our ministry is done by pastoral staff and lay-ministers herein referred to as “Ministers.” These individuals are not licensed as professional counselors or psychologists because they perform spiritual and biblical ministry and not secular or psychological counseling. If it becomes apparent that professional counseling may better address the member’s needs, the minister will immediately initiate an outside referral to a licensed professional counselor or psychologist.


GOALS, RISKS & BENEFITS 

There is always a risk of emotional side effects from ministerial counseling. Oftentimes, symptoms worsen before they get better. Biblical counseling sometimes brings up painful emotions. The goal is to confront issues and emotions together and work through them with solutions and healing in mind.

Under all circumstances, sexual contact between a minister and ministry recipient is prohibited. If any minister suggests or attempts sexual advances, the ministry recipient shall terminate the session immediately and report the incident to the Executive Senior Pastor, or any other Elder not involved in the ministry.


RIGHT TO PRIVACY/CONFIDENTIALITY 

All communication between the member and the biblical counselor becomes part of the Biblical Counseling Department records. Records are the property of Gateway Church in accordance with legal requirements.

While most communication between a member and the biblical counselor is confidential, the following limitations and exceptions do exist:

  • Gateway Church or biblical counselor determines that the member is a danger to himself or someone else. 
  • Gateway Church must report to the appropriate welfare agency if the member discloses abuse, neglect or exploitation of a child, elderly, or disabled person. 
  • The 2015 revisions to the Texas Reporting Law now extend the duty to report where any person believes that an adult was a victim of abuse or neglect as a child, and the person further believes that disclosure is necessary to protect another child, an elderly person, or a person with a disability. 
  • The member authorizes, in writing, that Gateway Church has permission to release records. 
  • Gateway Church is ordered by a court to disclose information. 
  • Gateway Church is otherwise required by law to disclose information.
  • If member occupies a leadership or ministry position, Gateway biblical counselor may disclose information to the person in authority over the member, in the event he or she deems it relevant to member’s fitness or ability to fulfill his/her position.
  • Officially recognized church staff and lay-personnel may also have limited access to your pastoral file. Any other person seeking access to your pastoral file may do so only with your written permission. However, Gateway Church cannot guarantee complete confidentiality with regard to the information received from you. 

Gateway Care gatewaypeople.com

  • In marriage or family ministerial counseling, confidentiality belongs primarily to the relationship and not solely to the individual. 

EMERGENCIES 

You should contact your primary physician, a local emergency room, or the local police department when necessary and appropriate. It is the member’s responsibility to seek the appropriate resources in emergency situations.


ARBITRATION 

Any claim or dispute arising from or related to this Agreement, other than a claim for injunctive relief as otherwise provided in this Agreement, shall be settled by mediation or arbitration in Southlake, Tarrant County, Texas, in accordance with the governing Rules of Procedure for Christian Conciliation of the Institute for Christian Conciliation. In the event that the Institute for Christian Conciliation ceases to exist during the course of this Agreement, arbitration under this section shall be conducted according to the rules of the American Arbitration Association. Judgment upon an arbitration award may be entered in any court otherwise having jurisdiction. The parties each agree to bear their own costs related to any mediation or arbitration proceeding.

By your signature below, you indicate that you have read and understood this statement, and any questions about this statement were answered to your satisfaction. You also indicate that if requested, you received a copy of this statement for your records.


I acknowledge that I have read and agreed to the above "Member Rights & Responsibilities".*
I acknowledge the information I have provided is true and accurate.
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Applicant's Name*
Picture of Driver's License
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Applicant's Name (Spouse)
Picture of Driver's License (Spouse)
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By submitting this Care form, I authorize Gateway Church to use my driver’s license and any documents submitted with this form to determine my eligibility for financial assistance.

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