MINISTRY CONSENT & RELEASE FORM
Haven of Refuge Pastorial Ministring from the Word of God.
In order to be fully informed about the pastoral ministering you will receive, please read through the following Consent & Release form, and print your name, sign, and date it at the bottom, if you accept the terms contained herein.
This form must be signed before we begin ministry the first session. Please be advised that couples receiving ministering should submit a form for each individual. Biblical ministering is provided to help you meet the challenges of life in a way that will please and honor the Lord Jesus Christ and enable you to fully enjoy His love for you and His plans for your life. We are confident that the Bible provides
thorough guidance and instruction for life.
Therefore, ministering at Haven of Refuge Ministries is based on the principles God has given us in Scripture rather than those of secular psychology or psychiatry. Our ministering staff has hundreds of hours of training and experience in biblical ministering but our counselors are neither trained in, nor do they practice, psychotherapy. The help you receive at Haven of Refuge Ministries is through ministering, not therapy.
We adhere to commonly accepted codes of privacy and confidentiality in ministering ethics.
It is understood (and agreed) that all statements, whether written or verbal, in your pastoral ministering sessions, are of a confidential nature, and ethically cannot be disclosed without written consent. There are certain situations, however, in which the law and/or our ethical commitments require that certain information can be revealed without your consent.
The following exceptions will result in confidentiality being waived.
• We reserve the right to report child abuse or suspicion of child abuse of any type to the proper authorities and/or the right to cause a report of child abuse to occur.
• We reserve the right to disclose to the appropriate person, agency, or civil authorities and harm that a person may attempt or desire to do one’s self or others.
•When a counselee is a member of or attends another church if may be necessary to talk to his/her pastors or elders.
• When someone knowingly and persistently refuses to renounce a particular sinful practice in may be necessary to enlist the assistance of others to encourage repentance and reconciliation. (Proverbs 15:22; 24:11; Matthew 18:15-20).
• When a counselor is uncertain how to address a particular problem and needs to seek advice form a more experienced counselor.
In certain instances a counselor may ask a trainee/ advocate to sit in on ministering sessions or a counselor pursuing certification may need to record a session for their supervisor.
Please be assured that our counselors prefer not to disclose personal information to others and that they will diligently work with you to find a way of resolving problem as privately as possible.
Rights as a Participant
• You are entitled to information about any procedures and, methods of ministering, techniques and possible duration of ministering.
• You have the right to end ministring at any time without any moral, legal obligations.
• You have the right to expect confidentiality within the limits described.
Waiver of Liability
In consideration for receiving pastoral ministering, guidance and encouragement, the person receiving ministering agrees to release and waive any and all legal claims of any kind against Haven of Refuge Ministries or its agents or employees arising from or relaying to participation in pastoral ministering.
I have read the above ministering Consent & Release form of Haven of Refuge Pastoral ministering. I accept these policies and desire to proceed with biblical ministering.
My electronic signature below indicates my informed consent to the guidelines below.
Additionally, by signing this document, I am, of my own free will, knowingly authorizing Haven of Refuge Ministries to render Biblical ministry to me.
I declare that I am fully capable of discerning good and bad advice, and release, Haven of Refuge Ministries, staff, employees, or any other associated ministry or organization from any legal liability, claim, or litigation arising from my participation in this voluntary ministry.
I affirm that no guarantee or assurance of any kind has been made to me with respect to the expected results of this ministry, outside of the promises made to all Christians in the bible.
I understand that I will not be given a psychological diagnosis based on the current Diagnostic and Statistical Manual of Mental Disorders. I also understand that those who provide care are not trained as and do not counsel as licensed psychologists, licensed psychiatrists, state certified therapists, or any other type of professional mental health care provider.
I understand that I will receive Biblical guidance based on the teachings and authority of God’s Word. I have been informed of the nature and purposes of Biblical ministry and that my consent can be revoked orally or in writing prior to and/or during the ministry session.
Furthermore, I understand that the minister to which I am assigned is not licensed, nor is required to be licensed, by the State of Oregon or any national certifying organization, as a professional counselor, fee-based counselor, social worker or therapist.
I understand that I will receive Biblical guidance based on the teachings and authority of God’s Word.
Print name here: ______________________________________________________________________