CARE MEETING INTAKE FORM [CHILD]
Thank you for reaching out to our Hero Care Team. We hope to provide help, support, and guidance to your child. We meet from one or two sessions, provide a safe environment, give resources as needed, and will transition them to take a stable next step, if needed.  

Filling out your Hero's intake assessment to completion is an important part of securing their appointment. It helps us in the preparation for our meeting as we pray for our time together and helps you & them preprocess what you may need. Answers are confidential and are used for ministry purposes only.

If you have not scheduled or had your appointment as the parent first, please do so here - https://thepillar.com/care/ - Thank you for helping us with this prerequisite before seeing your child.

Also, we are here to help support a healthy relationship between you and your child.  To help foster trust as we build this support, we will share with you only what is necessary to foster your child's trust in other healthy adult relationships. Let us know if you have questions.

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 480-426-8779.
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Today's Date: *
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Name of Child: *
Name of Parent: *
Address: *
Phone: *
Email: *
Gender: *
Required
What type of care appointment does your child need? *
What do you feel they need from the appointment?   *
Required
PERSONAL HISTORY
Why are you seeking a care appointment for your child? *
Have they received counseling or guidance in the past? *
Required
If yes, what type?  
What are your expectations and hopes from the care appointment? *
RELATIONSHIP WITH GOD & CHURCH
How does your child know Jesus? *
How long have you been attending Pillar Church? *
How often do they attend church? *
What is the name of the most recent church attended (before Pillar)? *
HEALTH
How is their physical health?: *
Do they currently take medications?:
Clear selection
Have they ever had a life-threatening or chronic illness?:
Clear selection
Is there a family history of mental Illness?
Clear selection
Pause:  Take a breath or two.  You're doing great.  Now, identify some of what they are experiencing:
They currently struggling
They have struggled in the past
Not Applicable (you can leave blank)
Anger
Anxiety
Arguing
Being Bullied
Bullies Others
Changes Due to Life Circumstances
Confused Thinking
Crying Frequently
Depression
Destructive
Eating Disorder
Emotional Abuse
Emotional Outburst
Fears
Has trouble making or keeping friends
Insomnia (trouble sleeping well)
Lack of Confidence
Lustful Thoughts
Lying frequently
Grief or Loss
Night Terrors
Obsessive Thoughts
Parent's Divorce or Chronic Relational Issues
Perfectionism
Phone Addiction
Physical Abuse
Sexual Abuse
Sexualized or Inappropriate Behavior
Somatic complaints (headaches / stomach aces / pains)
Substance Abuse
Suicidal Thoughts
Unhappy or Sad frequently
Verbal Abuse
Clear selection
Discussing life circumstances in this season is ...   *
Difficult (Holds a lot in)
Easy (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 [FOR YOUR CHILD]
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 Pillar 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, Pillar Church cannot guarantee complete confidentiality with regard to the information received from you.

5. Pillar Church 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 Pillar Church 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, click here - https://thepillar.com/care/ - 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.  We looking forward to meeting with you!  If you have questions about your appointment - please call 480-426-8779.

Thank you for completing the Pillar Church HERO'S CARE Meeting Intake Form.
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