One to One Caregiver Application

Name *
Name
Address *
Address
Phone *
Phone
Are you willing to commit to serve faithfully for a period of no less than two years (from the start of training) *
This includes: * the initial 50 hours of training * regular visits to your care receiver (weekly or a mutually agreed-upon frequency) *twice-monthly Small Group Peer Supervision.
Many caregivers have been made stronger in a caregiving ministry through the care they themselves have received, including care from mental health professionals. We affirm the work of mental health professionals, who have helped many individuals to experience growth and healing. Have you ever received treatment for any emotional or psychiatric problems? *
(If yes, someone from the One to One Ministry will speak with you about this so that the team may better understand its significance in your life and ministry.)
Have you ever been charged with a crime? *
References; Please provide two references (at least not affiliated with Heartland)
Name of Reference
Name of Reference
Phone of Reference
Phone of Reference
Name of Reference
Name of Reference
Phone of Reference
Phone of Reference
Please read and sign below. The information I have provided in this application is true and complete to the best of my knowledge. I give permission for the One to One Ministry, if it deems necessary, to call my references, secure a police background check on me, and consult with the treating physician(s) or other mental health professional regarding the nature of any treatment I have received for emotional or psychiatric problems. In addition, I understand that Heartland Church has the right to decide through prayer and collaboration between elders and staff whether to continue or discontinue my application process and/or decide if I am to become a One to One Caregiver at any time. *
Date
Date