Debrief Intake Form

These services are intended for cross-cultural missionaries and their families who have lived abroad for at least six months. If you are unsure of which service you need, fill out this form and we can help you determine what would be most helpful for you. Be advised: This is an extensive form and may take at least thirty minutes to fill out, and cannot be saved. For more information, please contact our office at info@compass-ministries.org or our Clinical Director at amanda@compass-ministries.org.

General Information for Debriefings

A Debriefing is a relational and intentional process that provides an opportunity for a missionary to tell their story–verbally processing past events with time and space to understand how these events affect them now and for the future. The goal of the Debriefing is to feel heard and understood, and to see a healthy path forward, despite the difficulties that occurred. Most Debriefings focus on the most recent term of service, but can be opened to include more personal history. A Debriefing can be held for individuals, couples, and families. Organizations are not given any information regarding the Debriefing content without the expressed written permission of the Client. If an organization requests Compass Ministries to do a Debriefing for assessment purposes, then the Debriefer may be asked to provide the organization with a general summary and recommendations. In this case, permission will be required by the Client, and the Client will be given a copy of the report. At Compass Ministries, we offer a children’s program for ages 7 and up that includes some time together as a family and some separate activities for the children. We cannot include children younger than 7 years old in our Debriefings; if they attend, we will help you arrange childcare. Because Debriefings are primarily a relational experience, it is strongly recommended that you participate in person. Our in-person Debriefings are offered in beautiful Tampa, Florida, so not only will we treat you to a personal experience, but we encourage you to take additional days to rest and rejuvenate at our nearby world-class beaches. On occasion, we can offer an online virtual Debriefing, so please request this if it is your only option.

Location: Tampa, Florida

Length: Individuals - 2 days

                 Couples - 2 days

                 Families - 3 days

                 9:00 am to 3:00 pm each day.

Accommodations: Compass Ministries does not provide housing for Debriefings, but we do have partnerships with nearby housing ministries. You are responsible to arrange for your own lodging. Some affordable options are:

• MissioSERVE Guest house (Contact MissioServe)

• Tampa Bay Baptist Conference Center (https://tbbcc.org/) where you can arrange for discounted housing options, or you are welcome to arrange for your own lodging.

Dates: We schedule Debriefings according to requests and the availability of the Debriefers. Please let us know ahead of time when you would like your Debriefing.

Cost: Two-Day Individual Debriefing - $300.00

            Two-Day Couples Debriefing - $400.00

            Three-Day Family Debriefing - $600.00

These prices include materials and lunch, if done in person. They do not include housing, transportation, additional meals, or babysitting.

Prices are the same whether done in-person or online. Debriefings can be paid for at: Service Payment.

If you are unable to pay for services, please ask your church or sending agency to pay for the Debriefing on your behalf. If you are still unable to pay for services, then email info@compass-ministries.org and request the application form for the Paul Hazlett Memorial Scholarship Fund. The Scholarship Fund is limited and may only cover a portion of the cost.

Personal Information

Stressors

Spiritual History

Information for Children

Informed Consent for Debriefings

I consent to be Debriefed by the Care Team of Compass Ministries. I understand that this is a completely voluntary process, and that I can stop at any time during the process. Debriefing is a relational process in which the realities of my past and their impact on my life are expressed and understood for the purpose of release, renewal and moving forward. I understand that I will choose what part of my past on which I wish to be Debriefed, and everything that I share will be held confidential by my Debriefers. The only exception to this confidentiality would be if I tell the Debriefers anything that leads them to believe that a minor child or an elderly adult are being abused, or that I plan to harm myself or someone else. In these cases, I understand that my Debriefers have a legal and moral duty to break confidentiality in order to prevent harm to myself or others.

In addition, I understand that my Debriefers are supervised by a Licensed Mental Health Counselor. The supervisor may have knowledge of the details of my situation, but the supervisor is also bound by confidentiality to the same extent as my Debriefers. In the event that I reveal a serious moral failure that would compromise the integrity of the Kingdom of Christ and His Church, my Debriefers will work with me to devise a plan of confession and restoration within my Mission Organization and Faith Community.

I understand that Compass Ministries is providing me with short-term Debriefing Services and that the care I receive is not intended to diagnose or treat any psychological problems.

I will give at least 24 hours’ notice to cancel a scheduled appointment.

Consent for Access to Health Care Information

This form gives Compass Ministries permission to use and/or disclose protected health care information for the purpose of treatment, payment, and health care operations within Compass Ministries.

In order for Compass Ministries to provide services to you, to maintain payment records, and to conduct our normal health care operations, we need your consent. This consent gives Compass Ministries permission to access your protected health information as needed. It does not allow us to release any protected health care information to any person or organization outside of Compass Ministries, except for those we have hired to help us conduct our work (these organizations will be called business associates), or when legally mandated by law. You may revoke this consent at any time by notifying us in writing. You cannot, however, revoke any action we may have taken to disclose your protected healthcare information before you revoked your consent.

You have the right to request in writing that we restrict the manner in which your protected health information is used or disclosed to carry out treatment, payment, or healthcare operations. We are not required, however, to agree to such requested restrictions. If, however, we agree to the requested restriction, Compass Ministries will honor the request and it will be binding from that point forward.

I hereby consent to the use and disclosure by Compass Ministries and its business associates of my protected health information for the purposes of treatment, payment, and healthcare operations.

Service Fees

Compass Ministries strives to provide quality care for Missionaries and their families at reduced costs. Click the box which indicates the service that you are requesting.

All payments for sessions are due on the day of service. Payment for Debriefings should be made before the first meeting. Payments can be made online at: Service Payments.

If you are unable to pay for services, please ask your church or sending agency to pay for your Compass Care services on your behalf. If you are still unable to pay for services, you may apply for the Paul Hazlett Memorial Scholarship Fund (link). The Scholarship Fund is limited and may only cover a portion of the cost.

By signing this form, I am agreeing to pay for the services that I receive from Compass Ministries.

Notice of Privacy Practices

Effective Date: September 1, 2025

Our Commitment to Your Privacy

Compass Ministries is committed to protecting your health information. We are required by law (HIPAA) to keep your health information private, provide you with this Notice of our legal duties and privacy practices, and follow the terms of the Notice currently in effect.

How We May Use and Disclose Your Information

We may use and share your health information for the following reasons:

• Treatment – To provide, coordinate, or manage your counseling and related services.

• Payment – To bill and collect payment for services provided to you.

• Healthcare Operations – To support daily business activities.

• Required by Law – When required by federal, state, or local law.

• Public Health and Safety – To prevent or reduce serious threats to health and safety.

• Health Oversight – For audits, investigations, inspections, and compliance.

• Legal Proceedings – In response to a court or administrative order.

• Law Enforcement – When required by law.

• Coroners, Medical Examiners, and Funeral Directors – As necessary.

• Specialized Government Functions – For military, national security, or correctional purposes.

• Business Associates – With outside organizations under strict agreements.

  
  

Your Rights Regarding Your Health Information

You have the right to:

• Access Your Records – Request to see or get a copy of your health information.

• Request an Amendment – Ask us to correct or update information.

• Request Restrictions – Ask us not to share certain information.

• Request Confidential Communications – Ask that we contact you in a specific way.

• Receive an Accounting of Disclosures – Request a list of certain disclosures.

• Receive a Paper Copy of This Notice – Request a paper copy at any time.

  
  

Our Responsibilities

We are required by law to maintain the privacy and security of your protected health information. We must notify you promptly if a breach occurs that may compromise your information. We will not use or share your information other than as described here unless you give us written permission. If you do give permission, you may revoke it at any time.

Changes to This Notice

We reserve the right to change this Notice at any time. The updated Notice will be posted in our office and on our website (if applicable).

Complaints

If you believe your privacy rights have been violated, you may file a complaint with:

Our Office:

Compass Ministries

1214 West Bearss Ave,

Tampa, FL 33613

813-374-3915

info@compass-ministries.org

Or with the U.S. Department of Health and Human Services (HHS), Office for Civil Rights. We will not retaliate against you for filing a complaint.

Contact

For questions about this Notice or your privacy rights, contact:

Privacy Officer

Roni Lacuesta

813-374-3915

Roni@compass-ministries.org

These privacy practices can be accessed on our website: compass-ministries.net

We require a signature below in order to provide service. By signing below, I acknowledge that I have received and read the Notice of Privacy Practices.