Counseling Application

*All Information Is Confidential 

Consent to Counseling Form

*Please Note: As church counselors, WE ARE NOT PROFESSIONALS, LICENSED PSYCHOLOGISTS, OR PSYCHIATRISTS. We simply offer you counseling based on the Word of God; and an opportunity for prayer led by the Holy Spirit.

(This form may be used by churches to explain their counseling practices and to reduce legal liability by obtaining informed consent from the people they serve.) 

Our Goal: Our goal in providing Christian counseling is to help you meet the challenges of life in a way that will please and honor the Lord Jesus Christ and enable you to enjoy fully His love for you and His plans for your life. 

Biblical Basis: We believe that the Bible provides thorough guidance and instruction for faith and life. Therefore, our counseling is based on scriptural principles rather than those of secular psychology or psychiatry. Neither the pastoral nor the lay counselors of this church are trained or licensed as psychotherapists or mental health professionals, nor should they be expected to follow the methods of such specialists. 

Not Professional Advice: Some of our counselors work in professional fields outside the church. When serving as counselors within this church, however, they do not provide the same kind of professional advice and services that they do in their professional capacities. Therefore, if you have significant legal, financial, medical, or other technical questions, you should seek advice from an independent professional. Our pastoral and lay counselors will be happy to cooperate with such advisors and help you to consider their counsel in the light of relevant scriptural principles. 

Confidentiality: Confidentiality is an important aspect of the counseling process, and we will carefully guard the information you entrust to us. There are four situations, however, when it may be necessary for us to share certain information with others: when a counselor is uncertain how to address a particular problem and needs to seek advice from another pastor or elder in this church; when a counselee attends another church and it is necessary to talk with his or her pastor or elders; when there is a clear indication that someone may be harmed unless others intervene; or when a person persistently refuses to renounce a particular sin and it becomes necessary to seek the assistance of others in the church to encourage repentance and reconciliation (see Proverbs 15:22; 24:11; Matthew 18:15-20). Please be assured that our counselors strongly prefer not to disclose personal information to others, and they will make every effort to help you find ways to resolve a problem as privately as possible. 

Resolution of Conflicts: On rare occasions a conflict may develop between a counselor and a counselee. In order to make sure that any such conflicts will be resolved in a biblically faithful manner, we require all of our counselees to agree that any dispute that arises with a counselor or with this church as a result of counseling will be settled by mediation and, if necessary, legally binding arbitration in accordance with the Rules of Procedure of the ______________________. Judgment upon an arbitration award may be entered in any court having jurisdiction. 

Agreement: By signing this consent, you agree that you will not attempt to subpoena or require any counselor to appear in any legal proceeding related to any matters discussed during counseling; nor will you attempt to subpoena any notes or records related to this counseling. 

Having clarified the principles and policies of our counseling ministry, we welcome the opportunity to minister to you in the name of Christ and to be used by Him as He helps you to grow in spiritual maturity and prepares you for usefulness in His body. If you have any questions about these guidelines, please talk with a pastor or elder. If these guidelines are acceptable to you, please sign below. 

Name *
Address *
Phone *
Date of Brith *
Date of Brith
Status *
Do You Attend Regularly? *
*3x's a month is regular
*Financially Martial? Pre-marital? Other?