About Us
Watch
Locations
Connect
Ministries
Groups
About Us
Contact Us
Elders
Leadership Team
What We Believe
New Here? Start Here
We are excited you are here! Plan a Visit Today!
Connect
Become a Member
Care
Classes
Events
Online Community
Plan Your Visit
Prayer
Serve With Us
Ministries
Business Leaders
Español
Global Outreach
Jewish
Kids
Local Outreach
Marriage
Men
Primetime
Prison
Single Parent Families
Widows
Women
Worship
Young Adults
Youth
Give
English
Espanol
Login
Intake Form - Health Need
Biblical Counseling Intake Form
Error
Work Entry
Added: 2/22/2026
Your Information
Campus
Dallas
Frisco
Grand Prairie
Jackson Hole
Justin
North Fort Worth
North Richland Hills
Plano
Prosper
Southlake
Campus is required.
First Name
First Name cannot contain special characters such as quotes, parentheses, etc.
First Name cannot contain emojis or special fonts.
First Name is required.
Last Name
Last Name cannot contain special characters such as quotes, parentheses, etc.
Last Name cannot contain emojis or special fonts.
Last Name is required.
Email
Email address is not valid
Mobile Phone
Mobile Phone is required.
Opt in to receive text messages | Message frequency may vary. Message and data rates apply. To end messaging with Gateway Church or for more information: Reply STOP to cancel. Reply HELP for help.
Birthdate
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
/
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
/
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
Birth Date cannot be a future date.
Gender
Male
Female
Address
Countries
United States
------------------------
Afghanistan
Aland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Saint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
British Virgin Islands
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Cook Islands
Costa Rica
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Ivory Coast
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Reunion
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
U.S. Virgin Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Vatican
Venezuela
Vietnam
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
AL
AK
AS
AZ
AR
CA
CO
CT
DE
DC
FM
FL
GA
GU
HI
ID
IL
IN
IA
KS
KY
LA
ME
MH
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
MP
OH
OK
OR
PW
PA
PR
RI
SC
SD
TN
TX
UT
VT
VI
VA
WA
WV
WI
WY
Marital Status
Married
Single
Divorced
Widowed
Preferred Language
Arabic
Armenian
ASL
Bengali
English
Farsi
French
German
Haitian Creole
Hebrew
Hindi
Italian
Japanese
Korean
Mandarin
Portuguese
Romanian
Russian
Spanish
Tagalog
Thai
Vietnamese
Other
Health Need Information
What is your current health need?
General Health
New Birth/Adoption
What is your current health need? is required.
Ministry Request:
Hospital Visit
Phone Call/Prayer
Other
Ministry Request: is required.
What kind of support are you looking for?
What kind of support are you looking for? is required.
Who is the best point of contact? First and Last Name:
Who is the best point of contact? First and Last Name: is required.
Point of Contact Email
Email address is not valid
Point of Contact Phone
Do you attend a Gateway Group?
No
Yes
Do you attend a Gateway Group? is required.
Any additional notes:
Care Team Details
What has led you to seek ministry/assistance?
What has led you to seek ministry/assistance? is required.
What are your expectations or hopes for receiving ministry?
What are your expectations or hopes for receiving ministry? is required.
Did anyone refer you for ministry?
No
Yes
Did anyone refer you for ministry? is required.
Please complete the captcha.