HFW Participant Application

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HFW Participant Application

If being completed by a minor (age 13-17, or defined by your state), a separate application must also be completed by parent/guardian.  Parents are asked NOT to read minor’s intake forms, to give the minor some level of privacy in there seeking help, and our attempt at establishing trust with your son or daughter.  

We are very glad that you are allowing us to be trusted with this information and to have the opportunity to help you.

Hope for Wholeness and all of our leaders commit to keep all of your information CONFIDENTIAL. After these questions are the details concerning our Release and Warn policy, our Confidentiality policy, and Donation for Services.

For strugglers (of participating Affiliates) this is the first of two intake documents that are necessary for full participation with Hope for Wholeness.  If you are sure you want and need our help, and are ready for more in depth help, complete both the HFW Participant Application and the Secondary Intake document prior to your first appointment.

Please be sure to be thorough in all of your answers. Even if you have spoken to a leader, please write your answers and details as having never spoken to anyone. This will help us in our care for you now and in the future.

We ask you contact our office, or the participating Affiliate, following your submission to schedule your appointment.  For Upstate, SC, support dial 864.583.7606.  Contact information for each leader can be found on our staff page.

Be SURE to copy/paste and/or print this form BEFORE hitting submit.

 

CONFIDENTIALITY

Hope for Wholeness leadership will hold as confidential all disclosures including:  documents, phone calls, emails, one-on-one meetings, and any information shared within the support group settings.

Exceptions to this confidentiality:

All leaders of Hope for Wholeness (HFW) reserve the right to discuss with other HFW leaders or HFW-approved professional counselors matters disclosed by individuals or group members for the purpose of receiving counsel, supervision, and oversight.

Anyone coming to Hope for Wholeness for counsel who discloses intentions to take harmful, dangerous, or criminal action against another human being or against themselves will necessitate that Hope for Wholeness leadership warn appropriate individuals of such intentions.

Suspected acts of child abuse or neglect will be reported.

A moral or ethical violation involving any HFW minor will be reported.

Discussion will occur in which a plan of action will take place.  The individual will be advised/consulted for any plans that would need to follow.  A period of time would be given to the individual for progress and self-disclosure if appropriate.

Those warned may include a variety of such persons: the person or family of the person who is likely to suffer the result of harmful behavior; the family of the group member who intends to harm himself/herself or someone else; associates or friends of those threatened or making threats; and/or law enforcement officials or child protection services.

 

RELEASE AND WARN

I acknowledge that I have voluntarily applied to Hope for Wholeness (HFW), a Christian, non-therapist, worship, teaching, discipleship, and mutual support program.  I further sign that I am of the legal age of consent of 18 years of age or older.

I am aware that the leadership of Hope for Wholeness are not licensed professional counselors.  I understand efforts by HFW and any of its members or leaders, do not consist of any form of formal training that has been accredited, licensed, or recognized by any state or federal government.

I am aware that my participation in Hope for Wholeness is not a substitute for psychiatric treatment, psychotherapy, and therapeutic counseling or any other form of professional therapy. I am also aware that my participation in Hope for Wholeness is not a substitute for my active involvement in a local Christian church body of my choice. I am voluntarily participating in Hope for Wholeness with full knowledge of these facts and I accept complete responsibility for my own psychological, mental, emotional, and spiritual well-being. I acknowledge that it is my responsibility to ascertain my own need for professional counseling and to seek such professional counseling, as needed. I further acknowledge that my participation in Hope for Wholeness does not create any special relationship of custody or control between myself and Hope for Wholeness (including any agent, employee, officer, or director of Hope for Wholeness) or between myself and any other person.

As consideration for being accepted by Hope for Wholeness to voluntarily participate in Hope for Wholeness programs, I, on behalf of myself and my assigns, heirs, executors, guardians and other legal representatives, hereby release Hope for Wholeness and its members (including all agents, employees, officers and directors) from any liability for any injuries suffered by me during my voluntary participation in Hope for Wholeness, resulting from the negligent acts or omissions of Hope for Wholeness, or any agent, employee, officer or director of Hope for Wholeness and its members, or resulting from the negligent acts or omissions of any other participant of the Hope for Wholeness Program.

Further, I, on behalf of myself and my assigns, heirs, executors, guardians, and other legal representatives, hereby agree that I will not make any claim against, sue, or seek to attach the property of Hope for Wholeness or its members (including any agent, employee, officer, or director) and that I waive all actions, claims, or demands that I now or hereafter may have, for any injuries suffered by me during my voluntary participation in Hope for Wholeness, resulting from the negligent act or omissions of Hope for Wholeness, or any agent, employee, officer, or director of Hope for Wholeness or its members, or resulting from the negligent act or omissions of any other participant of the Hope for Wholeness program.

 

DONATIONS FOR SERVICES

Hope for Wholeness is a 501-(c) 3 non-profit organization that solely relies on the good will of those it mentors and donors. We are aware that not everyone can afford to give at the rate that is suggested here. We are here to serve all those that come to us, regardless of their ability to give.

At the end of our time (unless you request otherwise in advance) a mention for your donation will be as follows: "If you have come prepared to give a donation for our time, you can do that after we pray." This will be the only mention of money during the time together.

The below amounts are minimum donation rates. We do ask that you please consider the needs of this ministry by giving above and beyond these amounts as you are led by God.

One-on-one mentoring time 

Our suggested rate is $60.00 per hour for individuals and/or families. Individual meetings last from one to two hours (average is 1 . hours). Family sessions typically last two to four hours, depending on the distance you have driven and the practicality of coming back. You may give at the appointment time or through our website.

Minimum donation after first 3 appointments 

For those who cannot afford the suggested rate, we will offer up to three (3) appointments at whatever rate you can afford. After these three (3) appointments, we ask that you give a minimum donation of $20.00 per visit.

If you are not able to attend one of our groups, our leaders are available for one-on-one mentoring at the rate above.

Tax Receipt/Deductibility 

Donations made to the ministry are tax deductible. You will receive a year end receipt for your donation. If you DO NOT WANT A TAX RECEIPT, PLEASE (Always) PAY WITH CASH. If paying with cash, and you want a tax receipt, make sure to say so at the time of your appointment.

Debit/Credit Cards Accepted 

If it helps towards giving a donation and helping with the purchase of materials, we do accept Debit/Credit Cards. We accept AMEX, MasterCard, Visa, and Discover.

Will you consider standing with Hope for Wholeness? 

We will have events for you to invite friends, family, and your pastor, etc. to. These are excellent opportunities to help us spread the word about Hope for Wholeness's work.

Please consider giving a donation above and beyond your donation for mentoring. Also please consider being a regular monthly donor to Hope for Wholeness.

Auto-draft is available on your debit/credit card or checking account. Your support will help change the lives of the many people that seek Hope for Wholeness out for help. Information for such a commitment will be available at the time of the appointment.

Materials as a part of groups 

Many of our groups do offer materials as a part of the group involvement. Purchasing this material is not mandatory. These materials for support groups are not part of the suggested donations for group involvement below.

Support group donations and involvement 

We strongly suggest you make changes to your schedule, to allow for you to attend our group program for at least one year. We ask that all those that participate give towards their involvement.

Many structured support groups through mentoring organizations require around $25.00 per week for participation. We ask that you give what you are financially able to. Remember that the ministry has large costs involved in being available for yourself and others. We suggest $5.00 to $25.00 per week, as you are financially able. A donation basket or bucket will be available at each group. Checks are to be made to Hope for Wholeness. Please write "support group" or "workbook" in the note line of your check to help us with our records. An envelope will be available for cash or debit/credit cards. You may also give a donation through our website.

Disabilities

Our Building is not handicapped accessible. Do you need assistance? If it will help we have a downstairs conference room or for wheelchairs we can use a local church facility. Are you hearing impaired? Do you need for us to arrange for an interpreter?

If you need assistance with any of these, please be sure to contact our office in advance, so that we can accommodate your needs.

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