Member Disclosure Form

The decision to enter into Pastoral Meetings is a serious commitment that can be a life-changing experience. Research has shown that individuals who understand “Godly” guidance are more likely to achieve favorable results. This document is designed for confidentiality and not to be shared.

Pastoral Meeting

With respect to my Biblical orientation and worldview for Pastoring, I believe that we are whole persons, with physical, psychological, social and spiritual aspects, so therefore I am committed to an integrated approach to Pastoral Meetings. These Biblical perspectives are based upon God's principles. I respect your religious/spiritual orientation and therefore whether we include discussion of the spiritual dimension of life in our time together will be entirely up to you.

I will agree to meet with our members regardless of age, color, culture, disability, ethnic group, race, religion, or economic status. I may decline a meeting with a member if I feel, in my pastoral judgment, that I cannot help them or if they would be better served with the services of another professional. If a referral elsewhere is needed, I will provide information regarding services for the member's consideration.

Pastor's Responsibility

As a spiritual leader, I will uphold and abide by the standards of the Word of God. Our relationship is a spiritual one. Our contact will be limited to the sessions you arrange with me. You will be best served while we are meeting if our relationship stays strictly spiritual and if our sessions concentrate exclusively on your concerns. You may learn more about me as we work together, but it is important for you to remember that you are experiencing me as a Pastor.

Meeting Session

The beginning sessions involve understanding your situation so that together we can develop specific, realistic goals, methods to accomplish them and the approximate length of time needed. It is important for you to be as open and honest with me as possible and work toward the goals we have agreed upon. The majority of the meeting session will consist of you talking about the issues you present and employing methods that can help make a positive difference in your life. This requires effort and active involvement on your part to understand and change your thoughts, feelings and behaviors.

Confidentiality

I regard the information you share with me with great respect. All information saved with me including notes and records as well as assessment results is confidential and will not be released to any outside person or agency without your written authorization and consent.

The following are circumstances in which I cannot guarantee confidentiality, either legally or ethically:

• If there is abuse (potential or actual) of children, persons with disabilities, and/or senior citizens. The law requires the Pastor to report it to the appropriate authorities.
• If disclosure is required to prevent clear and imminent danger to yourself and/or others.
• If mandated by a court of law.
• As the pastor I will determine if this meeting will need to be recorded as needed. Confidentiality concerning such recordings is considered the same as the meeting sessions themselves.

Session and Fees

I can assure you that my services will be provided in a professional manner and will be consistent with accepted ethical standards. After we decide on the frequency of appointments (generally once a week) and the appointment time, I will reserve this time for you. Sessions are usually 45 – 50 minutes long. It is possible to adjust the length of a session if necessary and should be agreed upon in advance. The number of sessions depends on the nature of the concerns. Typically, meetings will last 8-12 sessions for relatively specific concerns but may be longer or shorter depending upon the need.

The donation structure is as follows: Members may use Zelle to submit their donation. Please understand that you, the member, are fully responsible for your donation for services, and the donations are due prior to each session(s). Again, donations are accepted in the form of cash, check, and your Zelle account. Please note that if your check is returned for insufficient funds, you will be responsible for the bank charges incurred. Cancellation of appointments must be made 24 hours prior to your appointment. If the appointment is not canceled within this time period or if you do not show up for your appointment, you will be charged a $35 missed appointment fee. There is a one-time Intake form fee of $100, and you are asked to give a donation per session no less than $95, unless stipulated otherwise upon agreement with the member and Pastor.

In Case of Emergency

If you try to contact me by phone and I am not available, please leave a message on my voice mail. I will return calls within 24 hours. If you are unable to reach me in an emergency, contact 911 or go to the nearest hospital emergency room.

Social Media and Electronic Communications

Social Media is neither private nor confidential. Therefore, I will not seek out or accept “friend” requests or “follow” any current or former member on any social media platform. With this being said, I will not engage you in any public forums over the Internet, because to do so could blur the professional nature of our relationship and could compromise the privacy that I seek to guard. Electronic communications (E-mail, texting (SMS), etc.) are not encrypted or secure and may not be received in a timely manner. The best method is to contact the office, or the phone number given.

Complaint Procedure

If you are dissatisfied with our meeting, the most effective and productive way to deal with the situation and hopefully resolve it is to discuss it in our sessions together. Please feel free to ask any questions or clarify any confusion you may have about our meetings.