Intake Form

NORTHEAST OREGON COMPASSION CENTER

LAY CAREGIVER MINISTRY

Informed consent and release of liability form

This is a church-based ministry providing lay Christian biblically based caregiving.

Our caregiving is done by lay persons, not licensed as professional counselors. We offer volunteer caregiving and peer-support to individuals struggling with a variety of issues. All of our caregiving is free of charge; although donations are accepted.

Under normal circumstances, everything you discuss with our caregiver will be held in strict confidence. However, you should be aware that there are some situations in which your caregiver 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, client’s indications of bodily harm to others, involvement in a felony, suicidal intentions, and reasonable evidence of child or elder abuse or neglect. Your caregiver may be discussing your case with other lay caregiver staff. No information, except that required by law, will be shared outside the caregiving staff without your written permission.

You are free to discontinue caregiver at any time. Occasionally, caregivers will elect to discontinue caregiving. Should that happen, every effort will be made to find qualified help with another caregiver or elsewhere.

Most people find caregiving very helpful.  However, depending on the nature of your difficulty, you might also experience uncomfortable emotions such as anger, fear, and frustration during the course of caregiving. While your caregiver cannot remove these feelings from you, they will help you work through them, or find an alternative caregiver.

Caregiving can last from a few weeks to several months. We believe God will give guidance to both caregiver and client throughout the caregiving process. It takes hard work on the client’s part for positive change to occur. It is our experience that change happens over a process of time though caregiving.

Recognizing that all the staff of the Northeast Oregon Compassion Center, are volunteer personnel, and further recognizing that no fee is being charged for these services. I, the undersigned client of Northeast Oregon Compassion Center, consent to receive care on a voluntary basis as described above, and pledge my full cooperation in the caregiving process. I will be prompt in attendance and follow through with any written assignments to the best of my ability. I will truthfully and completely disclose the factual history of my individual situation to the best of my ability at all times. I consent, and forever release and discharge Northeast Oregon Compassion Center, its employees, agents, and assigns from any liability for disclosing in accordance with Oregon law those details necessary to be disclosed by a “required reporter” concerning my intensions to commit bodily harm to others, my involvement in a felony, suicidal intentions, and any evidence of child or elder abuse or neglect. I understand that these disclosures are required and that if I disclose the details of such things to my caregiver, my caregiver as a “required reporter” under the terms of Oregon law, must report them to the appropriate social or law enforcement agency.

The cooperative client is responsible for:
1. Making appointments to see Lay Caregiver in a designated setting. These appointments must have approval by the Lay Caregiver.
2. Being on time for appointments or calling in if delayed.
3. Keeping all appointments, and notifying the Lay Caregiver well in advance if they cannot keep or are being delayed.
4. Being completely truthful with the Lay Caregiver
5. Doing any homework assignments given by the Lay Caregiver
6. Demanding no more than agreed upon time of the Lay Caregiver
7. Keeping the process of caregiving confidential as it is a trust relationship between two parties.
8. Advising the Lay Caregiver directly if he or she is in any disagreement about the caregiving process or another issue.
9. Making every effort to complete the Caregiving process by an agreed upon time of termination.
10. Asking questions to clarify any points of confusion.
11. Being prepared for a Caregiving session.
12. Being able to terminate if necessary.
13. Keeping in mind that successful termination leads to good health.
14. Cooperating in the defeat of denial systems.
15. Being willing to be confronted in every area where confrontation is needed for growth to occur.
16. Keeping the Lay Caregiver abreast of any significant change(s)+- for example, if the husband or wife has left, or suicidal ideation has taken over the mind, the client notifies the Lay Caregiver.
17. A desire to cooperate in the healing process.
18. Working in partnership with the Pastoral or Lay Caregiver counsel.
19. Learning and placing value on effective two-way communication.
20. Staying on topic until completion.
ARTICLES OF ETHICAL GUIDELINES
FOR THE LAY CAREGIVERS Northeast Oregon Compassion Center

1. Personal commitment

1.1 I commit my service to God as a special calling.
1.2 I pledge to integrate all that I do in service with Christian values, principles, and guidelines.
1.3 I commit to seek direction and wisdom from God, while accepting responsibility for my own action and statements.

2. Loving Concern for Clients
2.1 I will accept clients regardless of race, religion, gender, sexual orientation, income, education, ethical background, value system, etc. unless such a factor would interfere appreciably with my ability to be of service.
2.2 I value human life, the sanctity of person hood, personal freedom and responsibility, and the privilege of informed free choice by adults in matters of belief and action.
2.3 I accept that my primary responsibility as a Lay Caregiver, or as a supervisor of trainees or interns, is to the client. I will not permit wither trainees or inters to perform services beyond their level of training. And I accept responsibility for the effect of their actions.
2.4 I will avoid exploiting or manipulating my client to satisfy my own needs.
2.5 I will abstain from unnecessary or prurient invasion of privacy.
2.6 I will take appropriate actions to help, even protect, those persons who are relatively dependent on other persons for their survival and wellbeing.
2.7 Sexual contact, or any harmful act with any client, student, or supervisee, as well as with former clients, students, or supervisees, or sexual exploitation of any of the above-both covert and overt-is prohibited and will be scrupulously avoided.
2.8 I will make every effort to avoid dual relationships that could impair my judgment or increase the risk of exploitation, in the provision of Lay Caregiving to students, employees, or supervisees, or by having business or close personal relationships with students, employees, supervisees, or clients.
3. Confidentiality
3.1 I will demonstrate utmost respect for the confidentiality of the client and others in the caregiving relationship.
3.2 I will carefully protect the identity of clients and their problems. Thus, I will avoid divulging information about clients, whether privately or publicly, unless I have received freely given, informed consent of the adult client or legal holder of confidentiality privilege for minor, in the form of expressed, written permission and the release of such information would be appropriate to the situation.
3.3 All records of caregiving will be handled in a way that protects the clients and the nature of their problem from disclosure.
3.4 The limits of confidentiality, such as those based on civil law. Regulations and judicial precedent, will be explained to the client.
3.5 Limit or exceptions to confidentiality include such situations as (1) when mandated by law, e.g. if child abuse is suspected or apparent: (2) when divulging information would prevent a clear and immediate danger to a person or persons: (3) if I am a defendant or subpoenaed witness in a civil, criminal, or disciplinary action arising out of caregiving wherein client confidences would be disclosed only in the course of such action.
3.6 I will be honest in dealing with clients, students, trainees, and colleagues.
4. Competency in Service Provided
4.1 I pledge to be well-trained and competent in providing serves.
4.2 I will refrain from implying that I have qualifications, experiences, and capabilities which are in fact lacking.
4.3 I will diligently pursue additional education, experience, professional consultation and spiritual growth in order to improve my effectiveness in need.
5. My Human Limitations
5.1 I will do my best to be aware of my human limitations and biases, and that I do not have complete objectivity or spiritual maturity.
5.2 I will avoid fostering any misconception a client could have that I am omnipotent, omniscience, or omnipresent.
5.3 I will make reasonable effort to provide referrals for client whom I am not capable of giving care to whether by lack of available time or expertise, or even because of subjective, personal reasons. Reasonable effort will be made to make referrals compassionately, clearly and completely, insofar as feasible.
5.4 I will resist efforts of any clients or colleagues to place demands for services on me that would exceed my relationships with my own family, other persons, or God.