Member Care Intake Form

I am a Metro District official worker *

First Name *

Last Name *

Email Address *

Mobile Number *

Church Name *

Ministry Title *

Best way to contact you: *

I am looking for (check all that apply): *

Check all that apply*:

Tip: *I am aware that in receiving coaching/counseling subsidies from the Metro District, that Member Care personnel will receive general progress information from the coach/therapist.

I have read and agree to the terms of the Metro District Member Care Policy and Procedures statement linked on the website. *

Tip: https://metrocma.org/wp-content/uploads/2022/02/Member-Care-Policy-and-Procedures-1.pdf

Thank you for filling out this form.

A care team member will contact you for further information and next steps. In the follow-up process, you will be asked to sign a member-care informed consent form.