New Relationship Coaching- Request Form

New Relationship Coaching- Request Form

Each individual in the relationship must fill out and submit a separate form in order to receive a coaching session.
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Are you and/or your significant other members of Church Tsidkenu?
How long have you been dating?
Which areas below would you like advice on or help with?

Healthy CommunicationPhysical BoundariesAccountability for PurityFamily BoundariesWork life balanceGeneral Wisdom and Advice
Are there any specific things you would like us to discuss during this coaching session?
Coaching Policy and Liability ReleaseInformation about Church Tsidkenu Inc. coaching methods and techniques is available to those who request it. Our coaching is Christian in nature, based upon the Bible. Coaches are encouraged to raise any questions they may have. Coaching CREDENTIALS:The Ministry leaders at Church Tsidkenu are not professionals in psychological counseling, psychiatric therapy, or marriage and family counseling or therapy, and are not licensed by the State of California as counselors, social workers, or therapists. CONFIDENTIALITY STATEMENT:The communications between you and your coach will be considered confidential except to the extent disclosure is required by law or in other instances in which the coach learns of potential threats of harm to self or others, including but not limited to cases of child abuse or neglect, suicide, domestic violence or other violence or physical threats, or homicide. In such instances, your communications may be disclosed to your coach's supervisor or to the Director of the TK Pastoral Care and Coaching Ministry and/or to appropriate state law enforcement authorities. Because this ministry is also a training center, and only with your consent, you may also be assigned a co-leader who is also bound by the duty of confidentiality imposed upon all coaches and leaders in this ministry. In addition, your coach may disclose the written and recorded records of your coaching sessions to his or her leader, clinical consultant, or other counselors to receive supervision regarding your care. By signing this document, you agree to such disclosure for supervision purposes only. MISSED APPOINTMENTS:A counselee who is unable to keep an appointment is asked to call the counseling center office to cancel. Failure to do so may result in termination of counseling. The counselors freely volunteer their time to this Ministry and extensive travel is often required. We appreciate your cooperation in this matter.Disclaimer & Liability Release:I, the undersigned, in consideration of the biblical counseling services provided by Church Tsidkenu Inc., do hereby agree to hold Church Tsidkenu inc., its counseling ministry, and its and their biblical counselors, employees, volunteers, and agents harmless from any and all past, present, future, known and unknown liability, actions, causes of actions, claims, expenses, damages, or injury incurred by me or my property as a direct or indirect result of any counseling services I may receive from Church Tsidkenu Inc., its counseling ministry, or its counselor(s). I have been informed of the nature and purposes of the Bible-based counseling ministry’s services. I understand that confidentiality is not guaranteed and that my consent may be revoked orally or in writing prior to and/or during my counseling session. Furthermore, I understand that neither the lay counselor nor co-counselor to which I am assigned are licensed by the State of California as professional counselors, social workers, financial counselors or advisers, or therapists, and that any desired results are not guaranteed as a result of said biblical counseling services. I further understand that it is the specific intent and purpose of this legally binding document to release, discharge, and indemnify for any and all claims and causes of action of any kind or nature that are directed toward Church Tsidkenu Inc., its counseling ministry, or its counselor(s) in connection with said biblical counseling service or any other associated activities. This includes causes which are known or unknown, specifically mentioned or implied, or neither mentioned nor implied, which might exist or be claimed to exist at or prior to the date of this document. I also understand that if any conflicts arise as a result of the counseling services that I receive, I agree to submit such issues to binding Christian arbitration conducted by the National Center for Life and Liberty or another Christian arbitrator and expressly waive any and all rights in law and equity to bring any civil disagreement before a court of law, except that judgment upon the award rendered by the arbitrator may be entered in any court having jurisdiction thereof. I agree to notify the counseling center office if I am unable to keep an appointment. I expressly agree that this release, waiver, and indemnity agreement is intended to be broad and inclusive as permitted by the law of the State of California, and that if any portion hereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full Page 3 of 3 legal force and effect. This release contains the entire agreement between the parties hereto and the terms of this release are contractual and not mere recitals. I further state that I HAVE CAREFULLY READ THE FOREGOING RELEASE AND KNOW THE CONTENTS THEREOF AND I SIGN THIS RELEASE AS MY OWN FREE ACT. This is a legally binding agreement that I have read and understand.

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