New Client Intake Form – The Hopeful Pastor

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What prompted you to seek services at this time? Is it a specific event, or something in your life that is bringing you stress or challenges? Please be as specific as you can.(Required)

Have you ever seen a counselor, therapist, or coach before?(Required)

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For what reason did you see a counselor, therapist, or coach previously?

Tell me about your current ministry role. What do you do? How long have you served there?(Required)

Is there anything else that you'd like to provide that would be helpful for me to know?

Informed Consent for Services(Required)

This document is designed to inform you concerning my background and to ensure your understanding of our professional relationship. My goal is to provide you with the following information so that you may make a fully informed decision about using my services.

MISSION, VISION, AND PURPOSE:

The Hopeful Pastor is an extension of the organization and ministry of Revive Counseling Center (also known as Revive Life Ministries, Inc.). Revive is a faith-based multi-disciplinary practice that seeks to provide help for people who are hurting emotional, spiritually, and physically. The operations of The Hopeful Pastor are governed by the policies of Revive Life Ministries, Inc.

While I cannot separate my mission from my faith, I will not force an expression of a particular faith tradition or view on clients receiving services through this program, and my approach to such matters will always be respectful and appropriate. I will use such spiritual helps as prayer and scripture only with permission and make no discrimination on the care I provide based on your response.

ABOUT DR. ZAKK GAMMON:

I am a professionally trained and licensed pastor, pastoral counselor, and coach. Specifically, I am a Licensed Clinical Pastoral Counselor and a Licensed Clinical Supervisor of Pastoral Counselors through the National Christian Counselors Association, a Licensed Christian Marriage & Family Therapist through the International Academy of Pastoral Counselors, and a Licensed International Representative of the Sarasota Academy of Christian Counseling. I am fully ordained through the local church as a Minster of the Gospel. I hold a Bachelor of Arts Degree in Christian Counseling, a Master of Arts Degree in Church Leadership, and a Doctor of Philosophy (PhD) Degree in Pastoral Counseling.

First and foremost, I am a Christian. As a Christian, I believe that attempting to hide my beliefs and providing value-free counseling, coaching, or consulting is both unwise and incredibly difficult to do. As such, I want you to understand what my beliefs are.

Like most counselors and coaches, I recognize that personal problems can come about because of physiological, social-environmental, and psychological pressures. However, I also believe that many problems may be spiritual in nature, resulting from either not understanding Biblical truth, or from sinful behavior. I also believe that individuals are created in God’s image, and can only feel complete and fulfilled through a relationship with God through His Son Jesus Christ.

Thus, faith-based counseling, mental health, and coaching services, as opposed to secular services, is very concerned with the spiritual as well as the physical and emotional needs of clients. The main goal of faith-based coaching and counseling services is to enable individuals to move toward greater spiritual, emotional and physical wellness. As a faith-based provider, I’m not limited to just psychological techniques or my human effort and wisdom. I believe God is the real authority in the process of providing services to clients and He gives us the resources to make changes in our life. I believe the services I provide services should involve praying about your difficulties, as well as looking to the authority of the Bible for the past, strength and comfort for the present, and hope for the future by trusting in God daily to meet needs and heal emotional wounds.

I seek to reflect the character of Jesus Christ and to love my clients as He does. While I am a faith-based provider, I will only use these tools to the extent an individual is comfortable with. I will not try to force a particular belief set, denominational stance, or faith tradition on you, but I do urge you to develop a relationship with Jesus Christ.

COACHING PROCESS:

If services are successful, individuals should feel they are able to face life’s challenges without my support or intervention after services have ended. Coaching, counseling, and consulting services sometimes allows unexpected personal issues to surface into one’s life. Change in your style of relation may impact significant others within your sphere of relationships. While some individuals may need only a few appointments to come to a resolution of their issues, others may require months or even a few years in a provider relationship.

Although our sessions will be based on honesty, it is important for you to realize that we have a professional rather than personal relationship. Our contact will be limited to the scheduled sessions you have with me, as well as an occasional email, phone call or text message via my business email or phone line. As flattering as it is to receive invitations into individual’s personal lives, please do not invite me to social gatherings, offer gifts or ask for me to relate to you in a personal way outside of your scheduled appointments. While there may be times when you interact with me in the community (either in-person or online), you will be best served if our relationship stays professional and if your appointments concentrate exclusively on your concerns.

It is impossible to guarantee any specific results regarding your goals during coaching. However, I assure you that my services will be rendered in a professional manner consistent with the accepted ethical standards and with the code of conduct established by the National Christian Counselors Association, for which I personally, The Hopeful Pastor as a brand, and Revive Life Ministries, Inc. as an organization subscribes. A copy of this code is available upon request from me by emailing hello@hopefulpastor.com, or by contacting the National Christian Counselors Association, 600 Apex Rd., Sarasota, FL 34240 or by phone at (941) 388-6868.

In the event you are dissatisfied with the services you receive for any reason, please let me know. If you have any questions regarding our relationship or the services offered through The Hopeful Pastor brand, please ask.

I agree

Notice of Privacy Practices(Required)

THIS NOTICE DESCRIBES HOW YOUR INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

I. MY PLEDGE REGARDING HEALTH INFORMATION: I understand that health information about you and your health care is personal. I am committed to protecting health information about you. I create a record of the care and services you receive from me. I need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this mental health care practice.

This notice will tell you about the ways in which I may use and disclose health information about you. I also describe your rights to the health information I keep about you, and describe certain obligations I have regarding the use and disclosure of your health information.

I am required by law to:

• Make sure that protected health information (“PHI”) that identifies you is kept private.

• Give you this notice of my legal duties and privacy practices with respect to health information.

• Follow the terms of the notice that is currently in effect.

• I can change the terms of this Notice, and such changes will apply to all information I have about you.

The new Notice will be available upon request, within your client account on The Hopeful Pastor website..

II. HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:

The following categories describe different ways that I use and disclose health information. For each category of uses or disclosures I will explain what I mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways I am permitted to use and disclose information will fall within one of the categories.

Federal privacy rules and regulations allow me to consult with another provider within the same field of discipline to discuss your case without your written authorization. An example of this consultation may be to consult with another coach or a counselor to discuss your case and get insight from another provider’s experience to better provide you care. In such cases, I offer as little information as possible to the professional with whom I am consulting, and I never release your name or any other personal identifying information about you.

III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION: Psychotherapy Notes. I do not keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501. As such, I will not nor am I required to disclose your records to any authority for any reason.

You are entitled to have a summary of your records released to a named individual or organization only with your permission and by signing Release on Information form with me. You can rescind this Release of Information authorization at any time after signing the document.

IV. YOUR PERSONAL INFORMATION WILL NEVER BE USED OR RELEASED FOR THE FOLLOWING REASONS.

A. Marketing purposes: As a coach, I will not use or disclose your PHI for marketing purposes.

B. Sale of PHI: As a coach, I will not sell your PHI in the regular course of my business.

V. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION.

Subject to certain limitations in the law, I can use and disclose your PHI without your Authorization for the following reasons:

A. Defending myself in legal proceedings instituted by you.

B. For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA.

C. Required by law and the use or disclosure is limited to the requirements of such law.

D. Required by a coroner who is performing duties authorized by law.

E. Required to help avert a serious threat to the health and safety of others.

F. When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.

G. For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.

H. For health oversight activities, including audits and investigations. For judicial and administrative proceedings, including responding to a court or administrative order, although my preference is to obtain an Authorization from you before doing so.

G. For law enforcement purposes, including reporting crimes occurring on my premises.

I. Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter- intelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.

J. Appointment reminders and related benefits or services. I may use and disclose your PHI to contact you to remind you that you have an appointment with me. I may also use and disclose your PHI to tell you about treatment alternatives, or other services or benefits that I offer.

VI. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT.

Disclosures to family, friends, or others. I may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your services, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.

VII. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:

A. The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask me not to use or disclose certain PHI for treatment, payment, or health care operations purposes. I am not required to agree to your request, and I may say “no” if I believe it would affect your care.

B. The Right to Choose How I Send PHI to You. You have the right to ask me to contact you in a specific way (for example, home or office phone) or to send email to a different email address, and I will agree to all reasonable requests.

C. The Right to See and Get Copies of Your PHI. You have the right to get an electronic copy of a summary of your coaching record and other information that I have about you. I will provide you with this electronic copy within 30 days of receiving your request, and I may charge a reasonable, cost-based fee for doing so.

D. The Right to Get a List of the Disclosures I Have Made. You have the right to request a list of instances in which I have disclosed your PHI for purposes other than treatment, payment, or care operations, or for which you provided me with an Authorization. I will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list I will give you will include disclosures made in the last six years unless you request a shorter time. I will provide the list to you at no charge, but if you make more than one request in the same year, I will charge you a reasonable cost-based fee for each additional request.

E. The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request that I correct the existing information or add the missing information. I may say “no” to your request, but I will tell you why in writing within 60 days of receiving your request.

F. The Right to Get an Electronic Copy of this Notice. You have the right get a copy of this Notice by e-mail.

VIII. EFFECTIVE DATE OF THIS NOTICE

This notice went into effect on December 1, 2024.

I agree to the Privacy Practices

Financial Policies(Required)

I’m so honored you’ve chosen to work with me at through at The Hopeful Pastor.

The standard rate for a session is $125.00.

METHOD OF PAYMENT:

Clients are required to pay for services at the time of service by debit or credit card stored on file. By signing this agreement, you also authorize The Hopeful Pastor to charge your debit or credit card on file for the cost of services, and if you break the cancelation policy, as outlined below.

INSURANCE, HSA, & FSA REIMBURSEMENT:

Coaching, counseling, and consulting sessions through theat The Hopeful Pastor are not reimbursable through insurance. However, many Flex Spending Accounts and Health Savings Accounts may cover the cost of these services or reimburse you for the cost of services. You may place an HSA or FSA card on file to pay for sessions. If your HSA/FSA plan does not provide you with a debit card to pay for services, a receipt can be provided for the appointment, and you may submit it to one of these accounts if you choose.

Please note: I cannot verify these benefits are available through your HSA or FSA plan, and cannot guarantee payment from these plans. It is up to each plan to determine if they will reimburse you. For specific questions about HSA and FSA plans, contact your company’s Human Resources or Personnel division, or contact your plan directly.

CANCELATION POLICY:

Your appointment fee will be charged to the debit or credit card on file if a 24-hour notice is not given for cancelation.

Additionally, if you are a “no-show” to your appointment without notification of cancelation, this fee will be charged to your debit or credit card on file. You are considered a “no-show” if you have not logged on to your virtual session within 10 minutes of your session start time.

COURT APPEARANCES, LEGAL MATTERS, & PERSONNEL ISSUES:

I do not voluntarily participate in, testify for, or provide documentation for court cases, legal issues, depositions, attorney communication, or consultations with Human Resources or Personnel representatives. The services provided to you at The Hopeful Pastor fall under the category of faith-based coaching services. As such, appointment records and sessions notes are not considered medical or therapy records, and will not be released to an outside entity such as an attorney, court, or Human Resources department, nor can they be subpoenaed by a court.

Please be advised that if I receive a subpoena to testify in a court case or deposition for any matter, I will not make a legal or medical recommendation, nor am I required by law to participate in such activities when operating in the capacity of a faith-based Christian coach.

For pastors and church leaders specifically, if requested, I will interact with and provide information to your church’s oversight or governing authority as it relates to your participation in the coaching process and anticipated or witnessed outcomes. An example of this arrangement would be if a pastor has experienced a moral failure, and that pastor’s governing authority requires the pastor to undergo treatment such as counseling or coaching in order to retain their employment or position within the church.

To speak with or prepare information for one of these bodies, I will require a signed Release of Information form from you.

Fees associated with providing this information include $35.00 to prepare a written report about your participation in the coaching process as well as anticipated or witnessed outcomes (per report), or a prorated amount of my hourly fee ($125.00) for a phone or video conference. (Prorated amount determined by the length of the call.)

Furthermore, by agreeing to this document, you recognize that I cannot be responsible for the outcome or any judgement made in a court, church, or employment case.

I understand & agree to The Hopeful Pastor Financial Policies

Appointment Deposit(Required)

A deposit of $10.00 is required to reserve your appointment time. The remaining balance of $115.00 will be charged to the card you place on file following your appointment.

Price:

Credit Card(Required)

This card will be charged $10.00 to reserve your appointment. The remaining balance will be charged to this card following your appointment, in accordance with the Financial Policies.