Confidentiality Agreement Form

General Guidelines
General Guidelines can be found in the All Nations Worship Assembly Counseling Disclosure Form. The Form is Attached Below:

All counseling attendees must read and sign this agreement. As a trained counseling agent, it is important that notes for each session is taken copiously. Note-Taking is used to connect certain themes (i.e., rejection, abandonment, lust…) to other scriptural based understandings that bring authority to and over the case that is observed during counseling. Also taking notes of the specific guidelines pertaining to Pastoral Care (such as the responsibility we must take when encountering personal information of church members.) Confidentiality is not only for the protection of those within the person being counseled, but also for the counselor.

Bridging of Confidentiality
Information should be kept confidential, except for the following provisos that should be made clear at the outset:

  • If the information is required by law. For example, if a child under the age of 16 (or legal age in your country) has been abused or is in danger of being abused or is in need of care.
  • If it affects the person’s position in church.

Always let people know that if they disclose anything that is against the law, we must report the situation to the appropriate authorities (i.e. oversight = Frontline Pastors) as our duty of care.

All Nations Worship Assembly Chicago
Counseling Ministry Disclosure and Personal Data Form (Below)

Please read this important information carefully and ask for clarification on any questions you have.

Our Ministry Team: The Pastoral Counseling Ministry offers Biblically – based, Christ centered counseling to individuals and couples within the All Nations Worship Assembly congregation. Our ministry team consists of trained, licensed and certified mental health professionals as well as trained pastoral and volunteer counselors (i.e. Ordained Elders and Office Staff).

Our Approach: Our approach to counseling holds that all people are designed to be in a vital and intimate relationship with God, through Jesus Christ, and with others. We believe that a breakdown in either our relationship with God or other significant people will result in pain and distress. Therefore, facilitating the restoration of these vital relationships is an important part of the counseling process. With this in mind, our ministry team assists others in discovering and changing the unhealthy ways that they may be dealing with painful emotions, distorted thinking or unhealthy ways of relating to others. Prayer, the application of Biblical principles, helping skills and interventions along psychological principles that are consistent with scripture may also be used.

Placement and/or Referral: We strive to match your need with an appropriate member of our ministry team. We are ethically required to refer issues that are outside the scope of our ministry, or issues that we cannot address in a timely manner, to other professional providers. Your assigned counselor can review their training and experience with you on your first session. Exceptions or changes in counseling placement require the ministry Director’s approval. Furthermore, we do not render any financial, legal or medical opinions and/or advice.

Qualifications of Lay Counselors: Because of the Biblical and spiritual nature of this ministry, we train our own volunteers for the ministry of lay counseling. Some of our counselors are professionally trained, licensed or certified. However, our Lay-counselors and other volunteers do not possess professional licenses or certifications issued by the State of Illinois for the practice of professional counseling, marriage and family therapy, or social work specialties; nor do they necessarily possess the required education, experience or training for such licenses.
Limitations of Confidentiality: Information disclosed to the counselors is considered confidential in nature and ethically cannot be disclosed, without written consent. In pre-marital, marital or family counseling, all members involved in the counseling must sign a release. The following are exceptions that will result in confidentiality being waived:
1. Suspicion of child/elder abuse – We reserve the right and/or may be mandated by law to report child abuse or suspicion of child/elder abuse of any type to the proper authorities.
2. Threats to harm self or others – We reserve the right and/or may be mandated by law to disclose to the appropriate person, agency or civil authorities any threats of harm that a person may attempt or desire to do to one’s self or to others.
3. Necessity of supervision – To insure the highest quality counseling outcome, our ministry functions as a “ministry team.” As a result, your lay counselor or intern will be supervised by one or all of the staff counselors. In addition, staff counselors also utilize peer supervision on an ongoing basis to provide the highest quality of service to our clients.
4. Necessity of consultation – We reserve the right to consult with other counseling professionals or appropriate church ministry staff members regarding your sessions. This consultation will be held in the same level of confidence as your sessions.

No Court Testimony: The counseling we provide is faith-based and spiritual in nature. Chicago law prohibits compelled disclosure of these counseling exchanges, notes or records in any court of law. Accordingly, our counseling team will not provide court testimony and by signing below you are acknowledging this strict confidentiality and further agree that neither you nor your legal representative will attempt to subpoena your counselor for testimony.

Waiver of Liability: In consideration for receiving any form of counseling from the Pastoral Counseling Ministry of ANWA, the person receiving the counseling agrees to release and waive any and all claims of any kind against the ministry, staff, interns, lay counselor(s) or the Church, which may arise from, result out of, or be related to conduct or advice given.

Resolution of Disagreements: If a dispute should arise between the person receiving ministry and the counselor (and/or the counseling staff or Church) regarding the counseling session or the counselor’s advice or conduct, one should bring this dispute to the attention of the Director of the Pastoral Counseling Ministry. If the dispute cannot be resolved at this level, all parties agree to resolve such dispute by submitting to the Church’s Executive Senior Staff team for full and final resolution and conciliation.

Counseling Files: All counseling files and their contents are the property of the Pastoral Counseling Ministry. Session summaries may be supplied, when appropriate, to other professional providers with your written release.
Days/Hours for Counseling: Sessions are available only during office hours and only on an appointment basis.
Generally speaking, sessions are offered during the following days and hours: Monday- Thursdays 10:30am-5pm. Not all counselors have the same availability.

Possible Waiting List: Due to the volume of requests we receive, our ministry is primarily to the All Nations Worship Assembly congregation. We will gladly see those in the community, especially those with no church home, when our schedule allows. Members of All Nations Worship Assembly will be given priority on our waiting list. If our waiting list is prohibitive, we will offer outside referral options.

Session Duration: Our ministry is designed to offer short-term counseling, typically ranging 3 sessions. Issues requiring more extensive care may result in referral. A typical session is 60 minutes.
Canceling / Rescheduling: If you need to reschedule or cancel an appointment, we ask that you call at least 24 hours in advance. This allows us to reschedule others who are on our waiting list.
Emergencies: This ministry does not provide 24/7 or after-hours crisis intervention. Unless otherwise directed by your counselor, if you are in crisis you should call 911, the Suicide Hotline @ 1-800-SUICIDE or go to the emergency room of your choice.

What You Can Expect of Us: You can expect our ministry team to offer you acceptance, compassion and care as we provide Biblically based counseling that is within our scope of ministry. You can expect us to act on what we believe to ultimately be in your best interest aiming to promote in your personal, relational and spiritual growth.
What We Expect of You: Counseling is a cooperative venture with mutual responsibilities resting on both the counselor and the counselee. Therefore, we expect for you to approach the counseling process as an opportunity for personal change and spiritual growth; to focus on the changes God desires for your life, in the midst of your circumstances; to faithfully attend your sessions; to earnestly cooperate and participate in the counseling process as we all depend upon the guidance of God’s Word and the Holy Spirit; and to complete homework assignments that you and your counselor have agreed upon.

Termination of Counseling: Termination of counseling and/or referral occurs when (1) counseling goals have been achieved; (2) when the counselee no longer wants or does not return to counseling; (3) when meaningful progress is no longer being made; (4) when it is determined that the counselee’s needs are outside the scope of our ministry; (5) when the counselee is not abiding by the policies of this ministry, or not consistently showing for appointments. In all such cases the counseling file goes on an inactive status and rescheduling will require the counselor’s approval.

Informed Consent: I have read, understood and agree to all of the stated terms and conditions of this document and I voluntarily request to receive counseling from this ministry. I also understand that I may make a copy of this document if I so desire.