Request Care

Are you or your loved one in need of a place to call home while on the final journey toward Eternal Life?

The mission of Gospel of Life Disciples is to provide a gospel family for those at the end of life. Please fill out our care request form and our Dwelling nurse will contact you. After completing the form below, please do not hesitate to call or text us at: 405-778-1107.

Thank you, and God Bless!

NOTE: This is not an application for volunteering or becoming a live-in Lifeguard. If you are looking to volunteer or join our Discipleship school, please complete this form or email us.

I am...

The patient/applicant

The healthcare provider

The caregiver

THEIR DETAILS:

Patient/Applicant's Name

First Name

Last Name

Patient/Applicant's Date of Birth (DOB)

MM

DD

YYYY

Current Location of Patient/Applicant

Has the individual in need of care already been admitted to home hospice?

Yes

No

If so, which hospice agency is caring for this person?

Patient/Applicant's Primary Diagnosis

Any secondary diagnoses

Has the patient/applicant been assessed to have less than 90 days?

Yes

No

Briefly describe how we may be of assistance

YOUR DETAILS:

Representative's Name

First Name

Last Name

Representative's Email Address

Representative's Phone Number

(###)

###

####

I acknowledge and understand that the Gospel of Life Dwelling is not a healthcare hospice house or healthcare agency. I understand that it subsists on charitable donations and volunteer service.

“You are strangers no longer…you are members of the household of God…built together into a dwelling place of God in the Spirit.”

— Ephesians 2:19-22

Request Care

Gospel of Life Disciples + Dwellings