Counseling Consent Form

CONSENT FORM AGREEMENT BETWEEN THE CROSS CHURCH, COUNSELOR, AND COUNSELEE

I, the counselee named in the counseling intake form, desire to receive biblical counseling from The Cross Church, Pensacola. I acknowledge, agree, and give consent to the following:

I. DISCLOSURE 

(A) The Counselor assigned to me is trained in biblical counseling by the Association of Certified Biblical Counselors (ACBC), and may or may not have other certifications or degrees. The Counselor is not a licensed or certified psychotherapist, psychologist, psychiatrist, mental health professional, or social worker, and is not acting in such capacities. The counseling will be based upon Scriptural principles rather than principles of psychology or psychiatry. 

(B) The foundational principle of biblical counseling is that the Bible is sufficient to understand how to live a God-pleasing life and provide help for issues of relationship, conduct, emotion, and suffering. The Bible is inerrant and authoritative, wherefore Counselee agrees to submit to it as the final authority in counseling. The counseling will reflect the Counselor's understanding of the Bible and how its principles of Scripture apply to the Counselee's problems.

(C) Failure of the Counselor to interpret or apply the Bible in any particular way shall not subject the Counselor to liability. There shall be no legal or other liability that attaches to Counselor or any related institution or person for any advice, methods, conduct, or any act or omission related in any way to the service that is provided, and Counselee acknowledges that he/she is voluntarily seeking this counsel (free from coercion, duress, or pressure) with a full understanding of the nature, purpose, and effect of this agreement.

II. REQUIREMENTS

(A) Counselee will be required to complete weekly homework assignments and regularly participate in worship services at The Cross Church or another approved church throughout the duration of the counseling. Failure to complete weekly assignments or adhere to this policy will result in termination of counseling. Extenuating circumstances will be taken into consideration and approved at the sole discretion of the Counselor.

(B) Counselee will be given a folder at the start of counseling in which to organize all homework assignments, notes, and handouts. Counselee must bring this folder, along with a Bible to every session. 

III. CONFIDENTIALITY POLICY 

(A) The Cross Church Counseling Ministry strives to maintain a high level of confidentiality. Although counseling content remains private between Counselee and Counselor, Counselee understands that Counselor may communicate details of the counseling, including statements made, with relevant church Pastors should Counselor deem it necessary or helpful. Furthermore, if Counselee communicates something to Counselor that is sinful, which hinders the restoration of a relationship (i.e.: adultery, fornication, etc.), the Counselee will be exhorted to seek repentance through confession and forgiveness, and to commit to the process of reconciliation. If Counselee is unrepentant and/or unwilling to commit to the process of reconciliation, confidentiality may be broken in accordance with the biblical procedures set forth in Matthew Chapter 18.

(B) If there is a claim of, the observance of, or reasonable cause to suspect criminal behavior, safety risk, or detriment, Counselor will take reasonable measures to ensure the protection of the parties involved and all legal mandates to immediately report such activity or harm (potential or actual) to the appropriate governmental protection and/or law enforcement agencies shall be complied with. Counselors and pastors shall be entitled to seek a confidential legal opinion or advice from an attorney when it is deemed appropriate and helpful.

(C) Counselee may terminate counseling at any time by notifying the Counselor of his/her desire to do so. However, termination will not preclude Counselor from making the disclosures set forth above if deemed appropriate by Counselor, or if compelled by other legal means. Counselor is not required to keep records, but if records are made, Counselor may destroy any such records without incurring liability. Counselor will not provide records to Counselee for any purpose. 

IV. COUNSELOR-IN-TRAINING OBSERVATION POLICY

(A) Counselee gives permission to Counselor to allow counselors-in-training to observe during counseling sessions. The counselors-in-training will participate occasionally in counseling sessions but will otherwise quietly observe and take notes. Counselee understands the purpose of observation is to develop the counselor-in-training’s skills for the betterment of the ministry.

(B) Counselee understands that Counselor will dialogue with the counselor-in-training post-session, and the counselor-in-training will maintain the strictest and highest level of confidentiality. Such observers will be bound by the same confidentiality, qualifications and exceptions as stated above.

V. APPOINTMENT FEES AND CANCELLATION POLICY 

(A) The Cross desires to be a blessing to the community by providing facilities and Counselors who volunteer their time and services. Counseling services are offered free of charge, however, donations for the work of the ministry are gratefully accepted.

(B) The Cross requests that appointment cancellations be made directly with the Counselor as soon as possible (phone call or text message is acceptable), but not less than 24 hours before the scheduled session. We understand that emergencies arise, and that occasionally, this is not possible. The Counselor will work with the Counselee to the extent possible to reschedule at the earliest available time. 

(C) If the Counselee frequently cancels, does not show up for scheduled appointments, or cancels two or more appointments less than 24 hours in advance, the Counselor may require a $25 deposit cancellation fee payable in cash in order to proceed with further sessions. If after this, the Counselee fails to cancel at least 24 hours in advance or does not show up for an appointment, the $25 deposit will be forfeited and the same terms will be required to proceed again. If all sessions are attended or timely canceled, the cancellation fee will be returned at the final counseling session or when counseling is terminated. Exceptions for emergencies will be made on a case-by-case basis at the sole discretion of the Counselor. 

VI. DISPUTE RESOLUTION POLICY 

(A) If a dispute arises concerning the counseling of The Cross Church, or between a Counselee and the Counselor involved, (“The dispute”), there shall be no lawsuit initiated and the claim cannot be filed in any state or federal civil court. The parties understand that the Bible commands them to make every effort to live at peace and to resolve disputes with each other in private or within the Christian church.

(B) Instead, the dispute must be resolved as follows: The dispute may be submitted to the binding arbitration decision of the elders of The Cross Church, who will judge between the parties, applying the principles of First Corinthians Chapter 6 and Matthew Chapter 18, as well as any other applicable scriptures. If one or more elders of The Cross Church is a party to the dispute, then three arbiters will be selected from the elders of like-minded churches, with each party to the dispute choosing one arbiter, and the two arbiters then selecting the third. It is expressly understood that, by consenting in advance to such arbitration, the Counselee is waiving his/her right to a trial in the civil courts and that these Christian dispute resolution methods shall be the sole remedy for any such dispute or claim. By signing this consent, Counselee agrees not to attempt to subpoena or require any Counselor to appear in any legal proceeding related to any matters discussed during counseling; nor will Counselee attempt to subpoena any notes or records related to this counseling.

Online submission of the intake form and checking the Agreement box shall be considered your electronic signature.

BY SIGNING THIS DOCUMENT, YOU ARE IRREVOCABLY WAIVING ANY RIGHT THAT YOU MAY HAVE TO A TRIAL BY JURY OR JUDGE IN A JUDICIAL PROCEEDING. If any provision of this agreement shall be held invalid, illegal, or unenforceable, only that provision shall be stricken and the remainder of the agreement shall be in no way affected. By signing below, the parties agree to the terms and conditions set forth in this document and acknowledge that Counselor would not enter into this counseling relationship without each term set forth above.