Pastoral Counseling Agreement

Pastoral Counseling Agreement
The following is a standard agreement for everyone seeking counsel from Christ Community Church (CCC) through the counseling ministry. If you have any questions about this agreement, then please ask the counseling ministry staff. The men and women who provide biblical counsel seek to serve people according to the truth and grace of God’s Word. Our Pastoral Counselors hold graduate degrees in Pastoral counseling however are not licensed with the state of North Carolina.

The counselor assigned to help you will attempt to protect confidentiality in matters discussed during counseling sessions. There are limits to this confidentiality that may require your counselor to seek additional help for you or your family:
1) You made reference to harm yourself or someone else
2) You discussed ANY type of abuse of a child or elderly person known to you
3) Your pastoral counselor believes it necessary to involve another professional or overseeing pastor for supervision and referral purposes.

It is my understanding that I am entering into a process of counseling where personal and difficult issues may be discussed. While those with whom I counsel are expected to be respectful of my personal beliefs and opinions, I realize they will counsel me according to the Bible. There will not be a fee charged for counseling sessions. If I believe it necessary for my minor children to participate in counseling, then I give written permission for the counselors involved to meet and counsel with my children. If during the process of counseling I become uncomfortable with the process or unwilling to continue, then I agree to discuss this first with my immediate counselor and second (if necessary) with the leaders/pastors who oversee this counseling ministry. I have thoroughly read and agree to all that has been stated regarding the counseling ministry at Christ Community Church. I hereby release and hold harmless Christ Community Church and counselors from any and all liability, claims, and/or expenses related to or arising from any care or counseling received (or not received).
Signature

Agreement Questionnaire
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Sex:
Marital Status:
Occupation:
Emergency Contact & Phone Number:

Are you experiencing suicidal thoughts? If yes, please explain.
What are the concerns that bring you in for an appointment?
What have you attempted to do about them so far?
Please list any medications you are currently taking:
Are you seeking counseling from a Biblical perspective?

Release of Responsibility

I understand, Christ Community Church has established this ministry with the intent of helping all people find freedom in following Jesus, particularly by way of the counseling process.

I will not hold Christ Community Church liable for the counseling I receive or thought I should have received. I am entitled to a copy of the disclosure statement I signed.
Signature
General Reminders:
- Pastoral Counseling generally is short term therapy. A referral to a professional counselor may occasionally be necessary.
- It is free to see a pastoral counselor.
- As a courtesy, if you are unable to keep your appointment, please give 24-hour notice. CALL 910-690-3884 to cancel
- We want to serve you well, if there is any way we can improve our services, please let us know.
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Pastoral Counseling Agreement

Agreement Questionnaire