Informed Consent and Hold Harmless Agreement
We at Scope Ministries International believe God provides His written Word for guidance as to how we should live, with the real focus being on our relationship with Him. We believe the Bible is God’s wholly reliable instruction manual for life, and the purpose of our ministry is to teach its application. Our staff members and group facilitators are generally not state-licensed counselors, because they perform a different function. We are not “counselors” in the secular sense of the word. Instead of attempting to counsel individuals as to how they should conduct themselves, we teach a person’s understanding of and relationship with the Heavenly Father determines their conduct. What we offer is Biblical ministry, as opposed to secular counseling. Our staff does not possess the ability to change your life or fix your problems. Greater understanding and a different approach to life will only come through consistent effort on your part and cooperation with the Holy Spirit. The ultimate responsibility for growth and change rests with you and God. You are invited at any time to ask questions about the staff member or facilitator with whom you are working, their methods, and the direction their ministry with you is headed. While careful listening and empathy are a part of our Biblical process, the type of ministry offered by Scope is not passive, but directive in nature. Homework will occasionally be assigned based on the teachings and principles of Scripture. Assignments include reading, Bible studies and teaching tapes. Most people find our ministry helpful. Depending on the nature of your difficulty, however, you might experience uncomfortable emotions during the course of your growth in Christ. Sometimes, as a person begins to follow Biblical precepts, the situation may feel or actually become worse. That is not a good reason to think you are not making progress. To the contrary, it is an indication you are positively impacting your situation. When a person’s life becomes unmanageable, there is a need to “unlearn” certain beliefs, learn new beliefs, and establish new life patterns. This is often initially uncomfortable and may even bring additional friction in relationships, as adjustments to new ways of thinking and acting are made. You are free to discontinue our ministry process at any time. Most people continue until they have learned Biblical methods of thinking and acting. The Bible calls this process “renewing the mind”. Occasionally, Scope may elect to discontinue with a particular person. This usually happens when we see no substantial progress is being made, or other factors are interfering with the ministry process. Under normal circumstances, everything you discuss will be held in strict confidence. However, there are some situations where we may be required by law to report information without your permission or knowledge. These situations include, but may not be limited to: (1) indication of bodily harm to others, (2) involvement in a felony, (3) suicidal intentions, (4) knowledge of child or elder abuse/neglect. We might also be required to disclose information in response to a subpoena issued by a court of law. Please be considerate and on time for your appointments. If you need to cancel an appointment, please notify our office at least 24 hours in advance. Because we are also a training center, a Scope Ministries International trainee may occasionally participate in the process. Trainees are subject to the same confidentiality guidelines as staff. Scope Ministries International is an independent, inter-denominational, non-profit ministry. In accordance with other passages, and I Corinthians 6, we ask all who receive ministry from Scope Ministries International to read and sign this informed consent and to release Scope Ministries International, its agents and employees from any claim whatever arising from the undersigned’s participation in Scope’s ministry. “I have voluntarily sought Scope’s ministry on my own initiative, and am under no obligation to accept or reject any of the information that I may receive from Scope. I agree to hold Scope Ministries and its staff members harmless from any liability, loss or damage of any kind which arises as a result of the ministry received.” I have read and understand the above Informed Consent and Hold Harmless Agreement. I agree with and sign it as my free and voluntary act.
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date Picker Icon
Back
Next
Name
*
First Name
Last Name
Gender
*
Male
Female
Age
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Employer
*
Occupation
Email
*
Marriage Status
*
Single
Married
Divorced
Widowed
Number of Marriages
*
Number of Children
*
Children's ages
*
Spouse's Name
Spouses's age
Spouse's employer
Spouse's occupation
Is your spouse currently coming to Scope?
Yes
No
Have you taken 'Be Transformed'?
Yes
No
Explain briefly what problem brought you to Scope:
*
Have you made the discovery of knowing Jesus Christ personally?
*
Yes
No
How important is Christ in your daily life?
*
What hinders you from living the most effective Christian life?
*
What Church do you attend?
*
Church denomination?
How often do you attend Church?
*
Regularly
Occasionally
Seldom
Not at this time
Please check here to opt out of:
Class schedules, prayer letters and updates by regular mail
Email correspondence (Does not include contact for scheduling and cancelation purposes)
Disclaimer and release of liability
I understand that Scope Ministries International is a nonprofit Oklahoma Corporation that makes no charge for its services. Scope does accept donations. If you choose to make a donation to Scope you may use a simple rule of thumb of .1% of total yearly income as an hourly rate (i.e. $35,000 annual income would have a suggested donation rate of $35 per hour). There will be a charge for materials. I further state that I have voluntarily sought assistance on my own initiative and that I am under no obligation to accept or reject any of the guidance or help that I might receive from staff members of Scope Ministries. I agree to hold Scope and its staff members free from any and all liability, loss or damage of any kind, which may arise as a result of assistance, which I have received, or from my involvement with Scope. The number of sessions may be limited by the availability of the staff member. An evaluation will occur after 3-5 sessions. I have read this disclaimer and release of liability and understand and agree with it and have executed it as my free and voluntary act.
Signature
*
Date
*
-
Month
-
Day
Year
Date Picker Icon
Back
Next
Personal Statements
Check 'Yes' or 'No' if this statement describes you (most of the time).
I prefer to work with things rather than people
*
Yes
No
I internalize my frustration with others. I keep it to myself.
*
Yes
No
I'm often critical of myself.
*
Yes
No
People should keep the rules.
*
Yes
No
By the end of the day I feel tired.
*
Yes
No
People frustrate me.
*
Yes
No
I want others to invite me to events.
*
Yes
No
People are too inconsistent.
*
Yes
No
I do not like others inspecting my work/giving me advice.
*
Yes
No
I want to know what will happen next.
*
Yes
No
I'm always thinking.
*
Yes
No
I enjoy being alone.
*
Yes
No
I find it difficult to fall asleep immediately.
*
Yes
No
I want lots of information on the outcome before I act.
*
Yes
No
I dislike change.
*
Yes
No
I think of myself as analytical.
*
Yes
No
I want to be in control
*
Yes
No
I like a challenge.
*
Yes
No
Rules are frustrating.
*
Yes
No
People are lazy.
*
Yes
No
I like others to follow my plan.
*
Yes
No
I have lots of ideas most of the time.
*
Yes
No
I feel circumstances box me in.
*
Yes
No
People need to listen to me more.
*
Yes
No
Others lack the vision to help me accomplish my goals.
*
Yes
No
I prefer being the boss.
*
Yes
No
Problems challenge me.
*
Yes
No
Others often misunderstand me.
*
Yes
No
Others see me as harsh and uncaring.
*
Yes
No
When I get mad everyone knows it.
*
Yes
No
I like seeing things happen immediately.
*
Yes
No
I hate routine.
*
Yes
No
I enjoy being with people.
*
Yes
No
I enjoy staying up late when I'm with others.
*
Yes
No
My feelings are easily hurt.
*
Yes
No
Hurting others bothers me.
*
Yes
No
I hate routine work.
*
Yes
No
I prefer to work with people and not be left alone.
*
Yes
No
I enjoy social activities.
*
Yes
No
I often feel that others do not like me.
*
Yes
No
I dislike being rejected.
*
Yes
No
I dislike being alone.
*
Yes
No
I like to motivate people.
*
Yes
No
I cry easily.
*
Yes
No
I enjoy helping other people.
*
Yes
No
I like to include others in my projects.
*
Yes
No
I find myself easily influenced by others.
*
Yes
No
I like belonging to an organization.
*
Yes
No
Back
Next
Check the emotions you experience. I feel that i am or have been:
*
Abused
Boring
Can't do anything right
Disrespected
Failure
Guilty
Helpless
Other emotions not listed above?
Check ways you have attempted to fix yourself or your circumstances:
*
Bible Study
Counseling
Church attendance
Exercise
New Job
New location
New relationships
Other fixes not listed above?
Check which of the following describe things you have done or do at your worst or when you are depressed, angry, etc:
*
Alcohol
Moody
Seek attention
Blame others
Control
Cheat
Critical of self
Other worst actions not listed above?
Check the characteristics that describe your spouse (or individuals) at their worst, when you are at your worst. This person(s) is:
*
Abusive
Always right
Against me
Angry
Cheating on me
Controlling
Defensive
Other spouse or individual descriptions at their worst not listed above?
Back
Next
Scope Ministries International, Inc - Statement of Client Financial Responsibility
Scope Ministries, International, Inc. (“SMI”) provides pastoral counseling and biblical coaching and premarital pastoral counseling and biblical coaching as among the services it offers to the general public. Based on its more than forty (40) years of offering such services, it is evident that those who participate financially in the benefits they receive are more successful in achieving their related goals than those who do not participate. As fundamentally supported in the Bible, SMI strongly believes that every person who is financially able and is receiving services should participate financially in the cost of the services provided. However, SMI understands that not all clients receiving services have the ability to pay for such services. As a charitable organization, SMI ensures that no client is turned away for failure to pay. Pastoral Counseling and Biblical Coaching The cost to SMI for offering pastoral counseling and biblical coaching is approximately $150.00 per hour, and the salaries of the counselors and/or coaches are dependent, in large part, on SMI’s ability to receive donations and charitable gifts that sustain the costs. Because SMI is a 501(c)(3) tax exempt organization, your donation to SMI may be tax deductible based on your individual tax situation. Premarital Pastoral Counseling and Biblical Coaching The cost to SMI for offering premarital pastoral counseling and biblical coaching is approximately $250.00 for the first four hours and $65.00 per hour thereafter. The salaries of the counselors and/or coaches are dependent, in large part, on SMI’s ability to receive donations and charitable gifts that sustain the costs. Because SMI is a 501(c) (3) tax exempt organization, your donation to SMI may be tax deductible based on your individual tax situation. Intake Appointment The initial intake appointment for either type of service is provided at no cost to clients. During this appointment, SMI staff members may recommend that a client participate in one of the small groups that lay the foundation and/or supplement the counseling services. These classes may include “Be Transformed,” or “Intimacy with God,” and have proven highly effective in helping clients resolve many of the conflicts for which individuals seek counseling.
I have read the above information and understand the financial responsibility of a client receiving services at SMI. In seeking the counseling and biblical coaching services offered by SMI, I have prayerfully considered the needs of ministry and the services I will receive and believe God is directing me to support the ministry as follows:
*
The minimum suggested donation is based on a simple rule of thumb of 0.1% of total yearly income as an hourly rate (i.e. $35,000 annual income would have a suggested donation rate of $35 per hour)
I agree to the suggested donation of $150 or other donation (which I will specify below)
I agree to the suggested minimum donation for Premarital Counseling / Biblical Coaching of $250 for the first four hours, and $65 per hour for any additional hours (if needed)
Other donation amount
Donations may be made via cash, check, credit/debit card, PayPal or automatic draft.
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date Picker Icon
Submit
Should be Empty: