1-on-1 Soul Care Assessment                                  & Informed Consent Form
ABOUT THE MINISTRY
One-on-One Soul Care exists to serve as time-limited, focused care for those walking through difficult seasons to help them remain connected to the heart of Christ and His Church.
The goal of this ministry is to #1 provide space to process trials, sufferings, and sin in the context of God’s unwavering love and grace (Ps. 103:8-14), #2 to encourage participants to consider the Lord’s desire to minister to their feeble, broken hearts (Ps. 34:18, 22), and finally #3 to help participants practice courage in entrusting these circumstances to a body of believers for the sharing of burdens and restoration of life 
(Jm. 5:16). 

One-on-One Soul Care is not professional counseling. If the observation is made that professional counseling or another trained specialty is better suited and equipped to treat a participant’s current circumstances, the appropriate referrals will be made. 

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Email *
ASSESSMENT
First Name: *
Last Name: *
Email: *
Phone Number: *
Gender: *
Required
Marital Status: *
Birthdate (Month, Day, Year): *
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Please briefly describe your reason for reaching out to One-on-One Soul Care
(What is the main concern as you see it?): *
How long has the above-mentioned problem, circumstance and/or situation persisted? *
What do you hope to achieve through receiving help through One-on-One Soul Care? *
Are you currently experiencing suicidal ideation? *
Required
Have you attempted to commit suicide or homicide in the past? *
Have you ever inflicted burns or wounds to yourself? *
Are there any other risk-taking behaviors that you engage in? If yes, please explain. *
Have you ever been hospitalized due to mental health reasons? If yes, please explain. *
Have you ever taken or are you currently taking any mental health medication? *
Are you currently under the care of a physician? *
CHURCH INVOLVEMENT
Are you currently a member at Highland Baptist Church? *
Do you regularly attend Highland Baptist Church? *
If you are a member or attender of another local church, list below. 
How long have you attended or been a member of your local church? *
Are you currently involved in any ministries associated with Highland Baptist Church?  If yes, please list them.  Please also list any past involvement. *
Are you currently involved in any groups at Highland Baptist Church? (CG, ABF, or Soul Care groups).  If yes, please list them.  Please also list any past involvement. *
AVAILABILITY
While we do our best to identify a One-on-One Soul Care provider who has similar availability, no guarantees can be made that sessions will be scheduled during days/times requested.  Once a One-on-One Soul Care provider has been matched to a participant, that provider will reach out in the form of either telephone or email to arrange session dates/times.

In the box below, please indicate which day(s) that you are available to meet with a One-on-One Soul Care provider along with one or more of the following time frames: Morning, Afternoon, Evening.
For example: Tuesday and Thursday mornings, Friday afternoons
Mondays *
Required
Tuesdays *
Required
Wednesdays *
Required
Thursdays *
Required
Fridays *
Required
Saturdays *
Required
Sundays *
Required
INFORMED CONSENT
As a reminder, One-on-One Soul Care is not professional counseling.  If the observation is made that professional counseling or another trained specialty is better suited and equipped to treat a participant's current circumstances, the appropriate referrals will be made.

Participants will meet with a One-on-One Soul Care provider for four 50-minute sessions to discuss the participants current concerns, needs, and goals.  Homework may be suggested by the Soul Care provider to process insights throughout the week, but it is not required for participation.  The goal throughout four weeks of One-on-One Soul Care sessions is to connect the participant to the heart of Christ and to encourage connection to the body of believers.  This connection may be in the form of building confessional relationships, getting connected to a CG or ABF, or joining a Soul Care group offered by Highland.

Confidentiality/Limitations
Confidentiality is of utmost importance to the care providers in order to create a safe and trustworthy environment to process the hardships of life.  However, below list circumstances that require a provider to break confidentiality and report to the appropriate party:

1.  If a participant threatens or attempts to commit suicide or otherwise conduct themselves in a manner which there is substantial risk of incurring serious bodily harm
2.  If a participant threatens to inflict grave bodily harm or death to another person
3.  If the provider has a reasonable suspicion that a participant or other named victim is the perpetrator, observer of physical, emotional, or sexual abuse of children under the age of 18 years
4.  Suspicions as stated above involve a case of an elderly person who may be subjected to these abuses
I have read and agreed to the terms of the informed consent.
Please enter your first and last name. *
Please provide the date you are submitting this form. *
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