Care :: Confidential Support Request

For ongoing support during a challenging season of life, please complete the information below. A member of the Care & Recovery team will reach out to you and coordinate care for your specific needs. Please allow 2-3 business days for a response.

*Address Line 1
Address Line 2
*City
*State/Province/Region
*Zip/Postal Code
*Age:
*Date of Birth:
*Gender:
*Marital Status:
*Do you attend Mariners Church?:
*Is it OK to leave a voicemail?:
*Please describe briefly the circumstances that led you to reach out to Care and Recovery:

Statement of Informed Consent (Please Read Carefully before hitting “Submit”)

Limited Confidentiality

During your Care & Recovery Ministry spiritual care engagement, you may discuss issues of a deeply personal nature.

The care volunteer you will speak to will guard the information shared in strict confidence.  However, the following information will be reported to the appropriate governmental authorities and/or other affected persons or entities: 

 

  1. Disclosure of child abuse

  2. A disclosure of elder or dependent adult abuse

  3. A disclosure of spousal abuse

  4. A disclosure that you present a serious risk of harm to yourself

  5. A disclosure that you present a serious risk of harm to another person

  6. A disclosure which in the opinion of the spiritual care volunteer requires action to protect another congregant or; the church itself; or any other interest of the church.


Waiver of Liability

I am acknowledging that having sought spiritual care as such is adhered to by Mariners Church, a nonprofit religious organization, I hereby acknowledge their understanding of the noted conditions and further release from any and all liability, without recourse, Mariners Church, its agents or employees, from any claim arising from the undersigned's participation in the abovementioned spiritual care program. The same being identified as follows:


1. It is understood by the participant that all spiritual care activities will be provided by volunteer peers, not licensed therapists or professionals of any designation.


2. That all spiritual care provided in the Care & Recovery Ministry is provided in accordance with the Biblical principles as adhered to by Mariners Church, and are not necessarily provided in adherence with any local or national psychological or psychiatric association.


3. That no representation has been made, either expressly or implied, that spiritual care, as conducted by the abovementioned spiritual care volunteers, is accepted as customary psychological and/or psychiatric therapy within the definitional terms utilized by those professions.


Submitting this form indicates that I have read this Waiver of Liability and agree to the conditions of the Care & Recovery Spiritual Care Ministry. I also declare that all the information I provided in this document is true.


By clicking "Submit Form," you are indicating your acceptance of the conditions above