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Relational Care Intake Form
Thank you for reaching out. Answers are confidential and are used for ministry purposes only.

At the end of this assessment you will be able to schedule your appointment with the link provided on the last screen.
We look forward to our meeting with you. Please let us know how we can best serve you.

Today's Date: *
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Name: *
Your answer
Address: *
Your answer
Phone: *
Your answer
Email: *
Your answer
Check All that Apply: *
Required
Children [Names, Ages]: *
Your answer
What type of ministry are you looking for? *
PERSONAL HISTORY
Why are you seeking ministry? *
Your answer
Have you received counseling, guidance or pastoral ministry in the past? *
Required
If Yes, what type? *
Required
What are your expectations and hopes from receiving ministry? *
Your answer
YOUR RELATIONSHIP WITH GOD
How do you know Jesus? *
Your answer
How long have you been attending Gateway Church (Scottsdale)? *
Have you gone through Gateway to Life (Membership)? *
Do you regularly attend church? How often? *
What is the name of your most recent church (before Gateway)? *
Your answer
HEALTH
Rate your physical health: *
Do you currently take medications:
Have you ever had a life-threatening or chronic illness?
Have you ever struggled with the following issues?
I have struggled in the past
I am currently struggling
Worry
Rejection
Suicide
Unforgiveness
Anger
Shame / Guilt
Eating Disorder
Family History of Mental Illness
Insecurity
Night Terrors
Compulsive Thoughts
Obsessive Thoughts
Lustful Thoughts
Depression
Anxiety
Fear
Physical Abuse
Sexual Abuse
Verbal Abuse
Emotional Abuse
Chemical Addiction
Alcohol Addiction
Sexual Addiction
Gambling Addiction
Other issue that's not listed
Discussing your life circumstances is ... *
Difficult (I'm a vault)
Easy (I'm a pretty open book)
PLEDGE
I promise that all the information above is true to the best of my knowledge.
Type name to sign.
Your answer
MINISTRY AGREEMENT
In consideration for being permitted to participate in voluntary pastoral ministry, herein referred to as “Ministry,” and prayer ministry, herein referred to as “Prayer Ministry”, I, the undersigned, herein referred to as the “Ministry Recipient,” agree as follows:

1. This is a church-based ministry of Gateway Church providing Ministry and Prayer Ministry in individual and group settings. Our Ministry is done by pastoral staff and lay-ministers, herein referred to as “Ministers.” These individuals are not licensed as professional counselors, social workers, or psychologists because they perform spiritual and Biblical ministry and not secular or psychological counseling. If it becomes apparent that secular or psychological counseling may better address the Ministry Recipient’s needs, the Minister will immediately initiate an outside referral to a licensed professional counselor, social worker or psychologist.

2. Under all circumstances, sexual contact between a Minister and Ministry Recipient is prohibited. If any Minister suggests or attempts sexual advances, the Ministry Recipient shall terminate the session immediately and report the incident to the Executive Senior Pastor, or any other Elder not involved in the Ministry.

3. Under normal circumstances, your Minister will use their good faith efforts to keep your discussions in confidence. However, you should be aware there are some situations in which your Minister may be required by law to report information to the proper authorities without your permission or knowledge. These situations include, but may not be limited to: a Ministry Recipient’s intent of harm to self or others, involvement in a felony, suicidal intentions, and/or reasonable evidence of child, disabled or elder abuse or neglect.

Your Minister may also disclose information in response to a subpoena and/or court order issued by a court of law. Additionally, if you hold a leadership or ministry position, your Minister may also disclose information to the person in authority over you, in the event he or she deems it relevant to your fitness or ability to fulfill your position.

4. Officially recognized church staff and lay-personnel may also have limited access to your pastoral file. Any other person seeking access to your pastoral file may do so only with your written permission. However, Gateway Church Scottsdale cannot guarantee complete confidentiality with regard to the information received from you.

5. Gateway Church Scottsdale requires that parent(s) must be actively involved in any Ministry and/or Prayer Ministry that is extended to a minor child as determined by the Minister. At the discretion of the Minister, parent(s) will be required to make themselves accountable for active participation in Ministry and/or Prayer Ministry offered by Gateway Church Scottsdale.

6. Ministry Recipients with any concerns or questions about this agreement agree to raise them with their Minister at the earliest possible time.

7. This agreement, herein referred to as the “Ministry Agreement,” will govern all relations involved during the term of the ministry process. Should the Ministry Participant participate in Prayer Ministry, the Voluntary Release, Assumption of Risk and Indemnity Agreement will be incorporated as part of this Ministry Agreement. It is agreed that any disputes or modifications of this Ministry Agreement will be determined directly between the individuals involved. If this Ministry Agreement is not satisfactory, then it is further agreed that disputes and disagreements will be taken to the Gateway Church Scottsdale Board of Elders for mediation. In the event that a satisfactory resolution is not achieved, then it is further agreed that a mutually acceptable third-party mediator will be utilized. If the mediation is unsuccessful, then the dispute shall be submitted to Christian Arbitration under the Rules of Arbitration published by the Institute for Christian Mediation (HisPeace.org). All expenses incurred will be the responsibility of the party bringing the dispute.

I have read, understand, and agree to the terms of Ministry Agreement. *
Type name and date to sign.
Your answer
YOUR NEXT STEP
YOUR NEXT STEP is to schedule an appointment to talk through where you are or where you'd like to be, click here - https://calendly.com/gatewaycare - Review your schedule and choose the best available time.

PLEASE NOTE: All appointments are at our offices located at 8110 E. Cactus Road, Suite 100, Scottsdale, AZ 85260. We looking forward to meeting with you! If you have questions about your appointment - please call 480-426-8784

Thank you for completing the Gateway Care Intake Assessment form.

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