Sample Confidentiality Form for Church-based Peer Support
Sample Confidentiality Form for Church-based Peer Support Groups
[Program Name]/[Ministry Name] Confidentiality Policy [Program Name] leadership will hold as confidential all disclosures made in the context of the [Program Name] program with these three exceptions:
1) All small group leaders reserve the right to discuss matters disclosed by group members for the purpose of receiving supervision and oversight. This oversight will occur in group supervision meetings held by the group coordinator and attended by other small group leaders, and in supervision sessions held between the ministry director and an outside supervisor.
2) Any [Program Name] group member who discloses intentions to take harmful, dangerous, or criminal action against another human being or against themselves will necessitate [Ministry Name], [Program Name] leadership to warn appropriate individuals of such intentions. Suspected acts of child abuse or neglect will be reported. Those warned may include a variety of such persons as:
- the person or family of the person who is likely to suffer the results of harmful behavior;
- the family of the group member who intends to harm him/herself or someone else;
- associates or friends of those threatened or making threats, and;
- law enforcement officials or child protection services.
3) [Ministry Name], [Program Name] operates under the pastoral oversight of [Church Name]. [Program Name] leadership reserves the right to disclose general information to the pastors of [Church Name] for the purpose of pastoral oversight. I have read and understand this confidentiality policy, including its exceptions.
Name (printed) _____________________________________________