INFORMED CONSENT AND HOLD HARMLESS AGREEMENT
We at Scope Ministries International believe God provides His written Word for guidance as to how we should live, with the real focus being on our relationship with Him. We believe the Bible is God’s wholly reliable instruction manual for life, and the purpose of our ministry is to teach its application.
Our staff members and group facilitators are generally not state-licensed counselors, because they perform a different function. We are not “counselors” in the secular sense of the word. Instead of attempting to counsel individuals as to how they should conduct themselves, we teach a person’s understanding of and relationship with the Heavenly Father determines their conduct. What we offer is Biblical ministry, as opposed to secular counseling.
Our staff does not possess the ability to change your life or fix your problems. Greater understanding and a different approach to life will only come through consistent effort on your part and cooperation with the Holy Spirit. The ultimate responsibility for growth and change rests with you and God. You are invited at any time to ask questions about the staff member or facilitator with whom you are working, their methods, and the direction their ministry with you is headed.
While careful listening and empathy are a part of our Biblical process, the type of ministry offered by Scope is not passive, but directive in nature. Homework will occasionally be assigned based on the teachings and principles of Scripture. Assignments include reading, Bible studies and teaching tapes.
Most people find our ministry helpful. Depending on the nature of your difficulty, however, you might experience uncomfortable emotions during the course of your growth in Christ. Sometimes, as a person begins to follow Biblical precepts, the situation may feel or actually become worse. That is not a good reason to think you are not making progress. To the contrary, it is an indication you are positively impacting your situation. When a person’s life becomes unmanageable, there is a need to “unlearn” certain beliefs, learn new beliefs, and establish new life patterns. This is often initially uncomfortable and may even bring additional friction in relationships, as adjustments to new ways of thinking and acting are made.
You are free to discontinue our ministry process at any time. Most people continue until they have learned Biblical methods of thinking and acting. The Bible calls this process “renewing the mind”. Occasionally, Scope may elect to discontinue with a particular person. This usually happens when we see no substantial progress is being made, or other factors are interfering with the ministry process.
Under normal circumstances, everything you discuss will be held in strict confidence. However, there are some situations where we may be required by law to report information without your permission or knowledge. These situations include, but may not be limited to: (1) indication of bodily harm to others, (2) involvement in a felony, (3) suicidal intentions, (4) knowledge of child or elder abuse/neglect. We might also be required to disclose information in response to a subpoena issued by a court of law.
Please be considerate and on time for your appointments. If you need to cancel an appointment, please notify our office at least 24 hours in advance. Because we are also a training center, a Scope Ministries International trainee may occasionally participate in the process. Trainees are subject to the same confidentiality guidelines as staff.
Scope Ministries International is an independent, inter-denominational, non-profit ministry. In accordance with other passages, and I Corinthians 6, we ask all who receive ministry from Scope Ministries International to read and sign this informed consent and to release Scope Ministries International, its agents and employees from any claim whatever arising from the undersigned’s participation in Scope’s ministry.
“I have voluntarily sought Scope’s ministry on my own initiative, and am under no obligation to accept or reject any of the information that I may receive from Scope. I agree to hold Scope Ministries and its staff members harmless from any liability, loss or damage of any kind which arises as a result of the ministry received.”
I have read and understand the above Informed Consent and Hold Harmless Agreement. I agree with and sign it as my free and voluntary act.
Signed: ______________ _______ Date: ________20___
Spouse Signature: ____________________________Date: ________20___
Witnessed: ______________________________Date:___________20________
CONFIDENTIAL
SCOPE MINISTRIES INTAKE FORM
(please print) (for office use only)
Date ______________ Referred by _______________________ # _________________
Name ___________________________________ Male Female Age __________
Address ______________________________________ Home Phone ______________
City _____________________ State _______ Zip _________ Cell Phone __________
Employer ________________________________ Occupation _____________________
Daytime phone __________________ Email address: _________________________
Single Married _____ Separated _________ Divorced______ Widowed____
Years Date Date Date
Number of marriages ______ number of Children ___________ Ages ______________
Spouse’s Name ____________________ Age ________ Daytime phone ___________
Spouse’s Employer __________________________ Occupation ___________________
Is your spouse currently coming to Scope? Yes No
Explain briefly what problem brought you to Scope: _____________________________
________________________________________________________________________
________________________________________________________________________
Have you made the discovery of knowing Jesus Christ personally? Yes No
How important is Christ to you in your daily life? ______________________________
________________________________________________________________________
What hinders you from living the most effective Christian life? ___________________
________________________________________________________________________
What church do you attend? ______________________ Denomination ___________
How often do you attend? Regularly Occasionally Seldom Not at this time
DISCLAIMER AND RELEASE OF LIABILITY
I understand that Scope Ministries International is a nonprofit Oklahoma Corporation that makes no charge for its services. Scope does accept donations. If you choose to make a donation to Scope you may use a simple rule of thumb of .1% of total yearly income as an hourly rate (i.e. $35,000 annual income would have a suggested donation rate of $35 per hour). There will be a charge for materials.
I further state that I have voluntarily sought assistance on my own initiative and that I am under no obligation to accept or reject any of the guidance or help that I might receive from staff members of Scope Ministries.
I agree to hold Scope and its staff members free from any and all liability, loss or damage of any kind, which may arise as a result of assistance, which I have received, or from my involvement with Scope.
The number of sessions may be limited by the availability of the staff member. An evaluation will occur after 3-5 sessions.
I have read this disclaimer and release of liability and understand and agree with it and have executed it as my free and voluntary act.
Dated this _______________ day of ___________________ 200_____
___________________________________ ________________________________
Signature Witness
FOR OFFICE USE ONLY
Discovery group date: |
Time: |
Day: |
Purchased Book? |
Yes No |
Group Leader: |
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