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CARE MEETING INTAKE FORM
Thank you for reaching out to our Gateway Care Team. Answers are confidential and are used for ministry purposes only.

Filling out the assessment to completion is an important part of securing your appointment. It helps us in the preparation for our meeting as we pray for our time together and helps you preprocess what you need.

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 meeting with you. If you have questions, please call 480-426-8784.
Today's Date: *
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Name: *
Address: *
Phone: *
Email: *
Check All that Apply: *
Required
Children [Names, Ages]: *
What type of ministry are you looking for? *
What do you feel you need? *
Required
PERSONAL HISTORY
Why are you seeking ministry? *
Have you received counseling, guidance or pastoral ministry in the past? *
Required
If Yes, what type?
What are your expectations and hopes from receiving ministry? *
YOUR RELATIONSHIP WITH GOD
How do you know Jesus? *
How long have you been attending Gateway Church (Scottsdale)? *
Have you gone through Gateway Life (Membership)? *
Do you regularly attend church? How often? *
What is the name of your most recent church (before Gateway)? *
HEALTH
Rate your physical health: *
Do you currently take medications:
Clear selection
Have you ever had a life-threatening or chronic illness?
Clear selection
Have you ever struggled with the following issues?
I have struggled in the past
I am currently struggling
Not Applicable (you can leave blank)
Worry
Rejection
Suicide
Unforgiveness
Anger
Shame / Guilt
Eating Disorder
Family History of Mental Illness
Insecurity
Night Terrors
Compulsive Thoughts
Obsessive Thoughts
Lustful Thoughts
Grief (I've experienced loss)
Insomnia (trouble sleeping well)
Depression
Anxiety
Fear
Physical Abuse
Sexual Abuse
Verbal Abuse
Emotional Abuse
Chemical Addiction
Alcohol Addiction
Sexual Addiction
Gambling Addiction
Other Issue Not Listed
Clear selection
Discussing your life circumstances is ... *
Difficult (I'm a vault)
Easy (I'm an open book)
PLEDGE
I promise that all the information above is true to the best of my knowledge. *
Type name to sign.
CARE MINISTRY AGREEMENT
In consideration for being permitted to participate in voluntary pastoral CARE ministry, herein referred to as “Ministry,” and prayer ministry, herein referred to as “CARE 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 CARE Ministry in individual and group settings. Our Ministry is done by pastoral staff and lay-ministers, herein referred to as “CARE 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 CARE Ministry Recipient’s needs, the CARE Minister will immediately initiate an outside referral to a licensed professional counselor, social worker or psychologist.

2. Under all circumstances, sexual contact between a CARE Minister and Ministry Recipient is prohibited. If any CARE 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 CARE 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 CARE 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 CARE 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 CARE 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 CARE 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 CARE Ministry and/or Prayer Ministry that is extended to a minor child as determined by the CARE Minister. At the discretion of the CARE Minister, parent(s) will be required to make themselves accountable for active participation in CARE 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 CARE 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 CARE Ministry Agreement will be determined directly between the individuals involved. If this CARE 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 CARE Ministry Agreement. *
Type name and date to sign.
YOUR NEXT STEP >>> [Before you HIT SEND ... see below]
YOUR NEXT STEP is to schedule an appointment to talk through where you are or where you'd like to be, click here - https://caremeetings.gatewaylife.com - Review your schedule and choose the best available time.

PLEASE NOTE: All in person appointments are at our offices located at 8110 E. Cactus Road, Suite 100, Scottsdale, AZ 85260 or our Gateway Tempe Campus: 1137 E. Warner, Tempe 85284. We looking forward to meeting with you! If you have questions about your appointment - please call 480-426-8784

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