CAC Application

6. Release of Information (ROI) Policy

The Center for Apostolic Counseling appreciates the confidence placed in this ministry
and the associated practitioners by the pastors who faithfully support and provide
referrals for services. It is our desire to work closely with the pastor, when possible and
if applicable to the client’s overall well-being. It is recommended that the practitioner
obtain the necessary Release of Information for such engagement with the referring
pastor.

The Release of Information should contain the contact information for the practitioner,
the client, and the pastor. The Release of Information should clearly state that the client is giving permission for the practitioner to speak to the pastor about the treatment process (follow your state’s guidelines for the necessary wording). The Release of Information should be kept in the client’s record.

I understand that through the CAC Network that I will receive referrals and that those referrals will be served to the best of my ability. I understand that my work with CAC referrals will directly reflect on The Center for Apostolic Counseling.

I authorize any person, organization or company listed on this application to furnish you any and all information concerning my previous employment, education and qualifications for inclusion into the CAC Network.

I also authorize you to request and receive such information. In consideration, I agree to abide by the rules and regulations of the CAC, which rules may be changed, withdrawn, added or interpreted at any time, at the CAC's sole option and without prior notice to me.

I understand that no representative of the CAC has any authority to enter into any agreement for any specified period of time, or to assure or make some other personnel move, either prior to commencement of CAC Network inclusion or after I have become a part of the CAC Network, or to assure any benefits or terms and conditions, or to make any agreement, that is contrary to the foregoing.

Declaration & Signature

I authorize any person, organization or company listed on this application to furnish you any and all information concerning my previous employment, education, and qualifications for inclusion into the CAC Network. In consideration, I agree to abide by the rules and regulations of the CAC, which rules may be changed, withdrawn, added or interpreted at any time, at the CAC's sole option and without prior notice to me.

I understand that it is my obligation to maintain any license required in the jurisdictions in which I practice or plan to practice. I attest that all information on this application is accurate, truthful, and correct to the best of my knowledge. I understand that to falsify information is grounds for refusing to allow me into CAC Network or for removal from the CAC Network should I be included.

I understand that no representative of the CAC has any authority to enter into any agreement for any specified period of time, or to assure or make some other personnel move, either prior to commencement of CAC Network inclusion or after I have become a part of the CAC Network, or to assure any benefits or terms and conditions, or to make any agreement, that is contrary to the foregoing.

I understand that by joining the CAC Network I will support the CAC through positive promotion via word-of-mouth, social media, professional networks, church-related events, etc… I will financially support the CAC and understand the minimum suggested gift is $144/year or $15/month.

I hereby acknowledge that I have been advised that this application will remain active for no more than 90 days from the date it was submitted.
I understand that this application does not guarantee acceptance into The Center for Apostolic Counseling Network.