Care Connector Request

Your name *

Email address *

Which campus do you attend? *

Gender *

Marital status *

Birthdate *

Address *

Phone number *

Spanish is my preferred language *

Español es mi idioma preferido

In 2-3 sentences, describe the struggle that you are experiencing: *

How long has this been going on? *

How are you thinking/feeling about the situation? *

What steps have you taken to change the situation? *

Who else knows about this? How have they helped you? *

Informed Consent

Informed Consent
We are offering Biblical hope and help to the Harvest Bible Chapel (HBC) community. As part of our mission to train and equip others to provide care, we may have Care Connector(s)-in-training, HBC Care Ministry staff, elder(s), pastor(s), and HBC ministry leader(s) participate in meetings with us. Be assured that they are interested in your welfare and are held to the same standards of professionalism and confidentiality as our Care Connectors. We do not offer professional psychotherapy, clinical mental health counseling, or any other state-recognized counseling licensure. We are a church and our Care Connectors are under the authority of God’s word and our church elders. We believe that your ultimate hope and help comes when you bring an open heart ready to receive the Spirit of God and the Word of God in the community of God. We also believe that life difficulties are better weathered in friendship. This is why we will encourage you to you bring a friend or Growth Group leader with you to Care Connector meetings. This person will not be a co-Care Connector and must be willing to submit to the process we lay out as a care plan. Your Care Connector can clarify this person’s role in the first meeting.

Confidentiality
Confidentiality is an important aspect of the care process, and we will carefully guard the information you entrust to us. There are situations, however, when it may be necessary for us to share certain information with others:
1. When there is a clear indication that a care recipient wishes to harm him/herself or someone else.
2. When there is evidence or reasonable suspicion of abuse against a minor child, elderly person, or dependent adult.
3. If we are subpoenaed or court-ordered to disclose information.
4. In discussions with the pastoral staff or elders of HBC, previous Care Connectors and/or your advocate for the sole purpose of gaining information for your care, or to help in follow-up and after-care.
5. When a Care Connector is uncertain of how to address a particular problem and needs to seek advice and wisdom from another Harvest Bible Chapel staff member, or elder.
6. If you are a believer, attend our church and persistently refuse to renounce a particular sin and it becomes necessary to seek the assistance of others in the church to encourage repentance and reconciliation (see Proverbs 15:22; 24:11, Matthew 18:15-20)
In all of these situation, we will make every effort to be sensitive to your situation. Please be assured that our Care Connectors strongly prefer not to disclose any of this personal information to others. We will strive to help you resolve the difficult situations you are experiencing as discreetly as possible.

Having clarified the principles and policies of our care ministry, we welcome the opportunity to minister to you in the name of Christ. If these guidelines are acceptable to you, please indicate this by checking the boxes below.

Biblical Counsel Understanding *

I fully understand the care I receive will be based on the conclusions the Bible is inerrant and authoritative, and contains God’s answers to the issues of life, conduct and relationships, and will reflect the Care Connector’s understanding of the Bible and how the principles of scripture apply to the problems, questions or issues involved.

Please type your full name to serve as your electronic signature: *

Today's date: *

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