Basic Informed Consent Form

INFORMED CONSENT
PASTORAL COUNSELING AGREEMENT

In order to be fully informed about the pastoral counseling you will be receiving, please read through this following agreement, sign and date it at the bottom. This form must be signed and the intake form must be completed and returned to the church office before the first session. (Note to couples: Each individual should fill out their own set of forms.)

DESCRIPTION OF PASTORAL COUNSELING:

The goal of pastoral counseling is to help an individual think biblically about their current struggles in the context of a confidential, caring environment. A pastoral counselor relies on Scripture as the sole authority for faith and conduct and recognizes that lasting change is the result of the power of God, the grace of Christ and the indwelling ministry of the Holy Spirit. Guided by biblical principals, the Counselors role is to utilize guided questioning, empathetic support, problem definition, reflection/reading assignments, encouragement, and prayer to provide wise, biblical and faithful counsel to those who are hurting and in need.

QUALIFICATIONS:

Lynn Roush received her B.A. in Psychology from Taylor University. She then went on to complete a Master’s Degree in Counseling Psychology from Trinity Evangelical Divinity School where she took coursework in Biblical Theology, Doctrine, Old and New Testament, as well as the core classes in Counseling Psychology. Lynn completed an internship with a Christian inpatient counseling organization as well as worked with a Christian psychiatrist providing group therapy, marital counseling and individual counseling. Her areas of interest include (but are not limited to): marital and pre-marital issues, family dynamics, eating disorders, depression, anxiety and anger issues.

REFERRAL POLICY/DISCLAIMER

After reviewing the intake form, we will determine whether or not we feel we can provide you with the appropriate services and level of care needed. Clients will be referred outside of The Crossing Pastoral Counseling Center when treatment required is beyond the scope of care available here.

PASTORAL COUNSELING FEES

Each session is 50 minutes. Counseling sessions will take place in the prayer room at The Crossing. Please check in at the church office at the front desk. Payment is due at the beginning of each session and accounts must be kept current in order to continue counseling. Cash or checks are accepted forms of payment (checks made payable to “The Crossing”) Scholarships may be available if qualifications are met (please see Scholarship application).

***Please note that we are unable to accept insurance.***

CLIENT EXPECTATIONS

Please plan to arrive 10 minutes prior to your appointment so the session can begin on time. You may be asked to complete homework assignments, or purchase a book to be read in conjunction with your pastoral counseling. In addition, prayer, Scripture reading or memorization may be utilized as part of the counseling process. Your commitment to the counseling process will greatly determine the outcome of your experience.

CONFIDENTIALITY

Your pastoral counselor will adhere to commonly accepted codes of privacy and confidentiality in counseling ethics. There are situations, however, in which the law requires that certain information can be revealed without your consent. Under the discretion of the pastoral counselor, if there is any indication that you may be a danger to yourself or others, or are involved in the abusing of a minor, your information may be disclosed to appropriate mental health services or law enforcement. Also, an issue may occasionally arise that would benefit from the counsel or involvement of a pastor or another counselor at The Crossing. If deemed appropriate, your pastoral counselor may decide that a pastor be consulted to insure the quality of care you are receiving.

RIGHTS AS A CLIENT

1. You are entitled to information about any procedures, methods of counseling, techniques and possible duration of therapy.

2. You have the right to end counseling at any time without any moral, legal or financial obligations other than those already accrued.

3. You have the right to expect confidentiality within the limits described.

4. You have the right to authorize your counselor to consult with another professional about your therapy in writing.

MEDIATION AND ARBITRATION

Disputes arising out of or in relation to this agreement to provide services shall first be referred to mediation, before, and as a pre-condition of, the initiation of arbitration. The mediator shall be a neutral third party chosen by agreement of the therapist and client. The cost of such mediation, if any, shall be split equally.

CANCELLATION POLICY

We request that you notify your pastoral counselor at least 24 hours before your scheduled appointment time if you need to cancel a session. Failure to do so could result in payment of half of the fee for the missed appointment. If deemed necessary, this charge should be paid before or at the time of your next appointment to continue in the counseling relationship. Exceptions are for sudden illnesses and emergencies only.

CONTACTING THE CROSSING PASTORAL COUNSELING CENTER

To schedule an appointment, please email Lynn Roush at lynn@thecrossingchurch.com. If you need to cancel or reschedule your appointment, please email Lynn or call the church office at 256-4410 and leave a message. For emergencies after-hours, please call 911, or go to your local emergency room.

By signing below, you are acknowledging that you understand and accept the guidelines stated above.