Deliverance Intake Form

In consideration for being permitted to participate in voluntary prayer ministry, herein referred to as the “Prayer Ministry,” the undersigned, herein referred to as the “Releasor,” agrees as follows:

RELEASE, WAIVER, DISCHARGE AND COVENANT NOT TO SUE

Releasor and releasor’s personal representatives, assigns, insurer, heirs, executors, administrators, spouse and next of kin, hereby releases, waives, discharges and covenants not to sue Northwoods Community Church of Peoria, Illinois and its directors, officers, elders, pastors, deacons, ministry team members, employees, agents and volunteers, as well as its successors, affiliates, and subsidiaries, all herein referred to as the “Releasees,” from any and all liability to Releasor, and to

Releasor’s personal representatives, assigns, insurers, heirs, executors, administrators, spouses and next of kin for any and all loss, damage, or cost on account of injury to the person or property or resulting in the death of Releasor, whether caused by the negligence of Releasees or otherwise while Releasor is participating in the Prayer Ministry and any other activities in connection with the Prayer Ministry.

ASSUMPTION OF RISK

Releasor understands, is aware of, and assumes all risks inherent in participating in the prayer ministry. These risks include, but are not limited to, physical and emotional responses and reactions as a result of this Prayer Ministry.

INDEMNITY

Releasor agrees to indemnify Releasees from any liability, loss, damage or cost Releasees may incur due to the participation by Releasor in the prayer ministry whether caused by the negligence of Releasees or otherwise. Releasor assumes full responsibility for and risk of bodily injury, death or property damage due to negligence of Releasees or otherwise while participating in the Prayer Ministry.

Releasor expressly agrees that this Voluntary Release, Assumption of Risk and Indemnity Agreement, herein referred to as “Agreement,” is intended to be as broad and inclusive as permitted by the laws of the State of Illinois and that, if any portion of this Agreement is held invalid, it is agreed that a balance, notwithstanding, continue in full legal force and effect. This Agreement, along with the Ministry Agreement contains the entire agreement between the parties in regard to the Prayer Ministry.

Consideration for being permitted to participate in voluntary pastoral and religious counseling, herein referred to as “Counseling”, and prayer ministry, herein referred to as “Prayer Ministry”, the undersigned, herein referred to as “Counselee”, agrees as follows:

1. This is a church-based ministry of Northwoods Community Church providing Counseling and Prayer Ministry in individual and group settings. Our Counseling is done by pastoral staff and lay-ministers, herein referred to as “Counselors.” These individuals are not acting as licensed professional counselors, social workers, or psychologists because they perform religious counseling and not secular or psychological counseling. If it becomes apparent that secular or psychological counseling may better address the Counselee’s needs, the Counselor will immediately initiate a referral to a licensed professional counselor, social worker, or psychologist. If you believe that you have questions which would benefit from the assistance of a psychotherapist or other mental health professional, it is ultimately up to you to decide whether to pursue mental health services and, if so, to select the provider whom you wish to see.

2. Under all circumstances, sexual contact between a Counselor and Counselee is prohibited. If any Counselor suggests or attempts sexual advances, the Counselee shall terminate the session immediately and report the incident to the Executive Senior Pastor, or any other Elder not involved in the counseling.

3. Under normal circumstances, your Counselor will use their good faith efforts to keep your discussions in confidence. However, you should be aware there are some situations in which your Counselor 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 Counselee’s intent of harm to self or others, involvement in a felony, suicidal intentions, and/or reasonable evidence of child or elder abuse or neglect. Your Counselor may also disclose information in response to a subpoena issued by a court of law. Additionally, if you occupy a leadership or ministry position, your Counselor 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, Northwoods Community Church cannot guarantee complete confidentiality with regard to the information received from you. Because our guidance is spiritual as opposed to mental health in nature, it is also important for you to understand that the law may place limits on the confidentiality of the information that you share with us. We do not have the broad confidentiality privileges of a psychotherapist or other licensed mental health professional, so it is entirely possible that our records could be subpoenaed and/or that we could be required to testify in judicial proceedings involving you or your family members. If you have concerns about the confidentiality of any information you intend to share with Northwoods, you should consult an attorney before revealing the information to us. Please rest assured that we strongly prefer not to disclose your personal information and that, within the limits of the law, we will make every effort to protect your privacy.

5. Northwoods Community Church requires that parent(s) must be actively involved in any Counseling and/or Prayer Ministry that is extended to a minor child as determined by the Counselor. At the discretion of the Counselor, parent(s) will be required to make themselves accountable for active participation in Counseling and/or Prayer Ministry offered by Northwoods Community Church.

6. Counselees with any concerns or questions about this agreement agree to raise them with their Counselor 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 counseling process. Should the Counselee 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 disputed or modifications of this Ministry Agreement will be determined directly between the individuals involved. If this Ministry Agreement is not satisfactory, then it is further agreed that disputes and disagreements will be taken to the Northwoods Community 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. All expenses incurred will be the responsibility of the party bringing the dispute.