Appointment Worksheet Please answer the following questions to help Jonathan and/or Wendy prepare for your appointment. Name First Last Email Best Contact Phone#Important:Pastor Jonathan Hoover and Wendy Hoover are not mental health professionals. Jonathan and Wendy provide Biblically-based pastoral life coaching, which is not psychotherapy. If you would prefer to meet with a Christian mental health professional, please indicate that below, and we will be happy to recommend a referral.Having read the above statement I: Still wish to meet with Jonathan and/or Wendy Would like Jonathan or Wendy to recommend a referral Getting off to a good start:Please take a moment to tell me as much as you'd like me to know in advance about the story of what brings you in for our appointment:What would you like to be different in your life or relationship as a result of our meeting together?:Overall, I am happy in this relationship:Strongly DisagreeDisagreeI'm IndifferentAgreeStrongly AgreeDoesn't ApplyI believe getting help will make a difference for me/us:Strongly DisagreeDisagreeI'm IndifferentAgreeStrongly AgreeDoesn't ApplyI want this relationship to work; if I had the chance to walk away I would stay because I want to:Strongly DisagreeDisagreeI'm IndifferentAgreeStrongly AgreeDoesn't ApplyCONFIDENTIALITY EVERYTHING SPOKEN TO YOUR PASTORAL LIFE COACH(ES) HERE IS PROTECTED BY THE CONFIDENTIALITY STATUTES OF THE STATE OF KANSAS. THAT MEANS YOUR PASTORAL LIFE COACH(ES) WILL IN NO WAY DISCLOSE ANY INFORMATION WITHOUT YOUR WRITTEN CONSENT EXCEPT IN THE FOLLOWING SITUATIONS: (A) IF YOU THREATEN GRAVE BODILY HARM OR DEATH TO YOURSELF OR ANOTHER PERSON, YOUR PASTORAL LIFE COACH IS REQUIRED BY ETHICAL STANDARDS TO INFORM THE INTENDED VICTIM AND/OR APPROPRIATE LAW ENFORCEMENT AGENCIES; (B) IF YOU REPORT TO YOUR PASTORAL LIFE COACH YOUR KNOWLEDGE OF THE PHYSICAL OR SEXUAL ABUSE OF A MINOR CHILD BY AN ADULT OR OF AN ELDER (OVER 65) BY AN ADULT, YOUR PASTORAL LIFE COACH IS REQUIRED BY LAW TO INFORM THE APPROPRIATE CHILD WELFARE AGENCY WHICH MAY THEN INVESTIGATE THE MATTER; (C) IF YOUR PASTORAL LIFE COACH IS REQUIRED BY A COURT OF LAW (COURT ORDER) TO TURN OVER RECORDS TO THE COURT OR IS ORDERED TO TESTIFY REGARDING THOSE RECORDS.I have read and understand the confidentiality statement.* Yes PASTOR JONATHAN HOOVER AND HIS WIFE WENDY OFTEN COACH AS A TEAM, AND MAY NEED TO DISCUSS INFORMATION YOU SHARE ON FORMS, OR IN SESSION DISCUSSIONS IN ORDER TO BEST SERVE YOU.I Understand and Agree to the sharing of my information between Pastor Jonathan and his wife Wendy as necessary.* Yes If you cannot agree to the above two statements, please do not submit the form, and contact Wendy Hoover at wendy.hoover@newspring.org with your questions or concerns.