Community Care Session Disclosure Form

Community Care Session Disclosure Form

Care session scheduler and disclosure form Form Preview
  • Community Care Session

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  • Disclosure for Community Care

    Community Care is a service offered by CityChurch to help individuals in crisis, hereby referred to as Care Recipient, identify their immediate next step. Due to the high demand from a large community, Community Care sessions are limited to 50 minutes and two occurrences per year.

    Community Care Leaders, hereinafter referred to as CCLs, advise purely from a Free Grace Theological Perspective. CCLs are not licensed professionals and do not have the training or skill for the long term process of repairing severe emotional or relational issues.

    Additionally, CityChurch does not provide, in any form or manner, psychiatric treatment or clinical mental health counseling. Referrals to licensed mental health professionals may be provided upon request.

    CCLs reserve the right to cease any Community Care session, at any time, for any reason.

    Information shared by the Care Recipient will be held in confidence within the Community Care Leaders team.

    Limits of Confidentiality

    There are some situations in which CCLs are permitted or required to disclose information without either your consent or authorization. CityChurch provides for the following limits on confidentiality:

    1. If and when information is disclosed regarding the actual or suspected abuse, neglect, or exploitation of a minor, a vulnerable adult, or an individual with disability. The CCL will report, in good faith, this actual or suspected abuse to the appropriate agency.

    2. If and when information is disclosed regarding any suicidal ideation, plan, or intent on the part of the Care Recipient. The CCL will take appropriate measures, in good faith, and report this actual or suspected threat to the appropriate agency.

    3. If and when information is disclosed regarding any homicidal ideation, plan, or intent on the part of the Care Recipient. The CCL will take appropriate and reasonable measures, in good faith, to report and ensure the safety of the imagined and/or intended victims.

    4. If and when CityChurch Executive staff need to be consulted in issues of safety concerns.

    By inserting my initials and date below, I hereby acknowledge I have completely read and fully understand this Disclosure for Community Care services offered by CityChurch. Furthermore, by signing below, I hereby release CityChurch and its Community Care Leaders from any and all liability herein.

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