I understand that this counseling is not a medical or psychiatric service, but is exclusively the sharing and explaining of principles set forth in the Bible as applied to my personal situation.
I have voluntarily sought counseling at Christian Life Ministries. I am under no obligation or compulsion to accept this counseling or any advice I may receive during this counseling process. I further agree to hold Christian Life Ministries and its staff free from any and all liability, loss or damage of any kind that may arise as the result of the counseling.
I understand that Christian Life Ministries and any employee or other representative of CLM is offering this counseling voluntarily, at a voluntarily pledged cost, and that I or CLM can terminate or limit this counseling at any time.
I understand that any counselor representing Christian Life Ministries will respect and protect my right to confidentiality, however, the counselor has the freedom to disclose any information received in the following circumstances:
1. The information may be disclosed to law enforcement officers or other government officials if the
counselor believes that the information may be an actual, threatened or potential crime,
other violation of law, or other matter within the responsibilities of the officers or officials to whom
the disclosure is made.
2. The information may be disclosed to whomever the counselor feels should have it, if the counselor
believes it is about an actual, threatened or potential suicide, or other act of self-harm.
3. The information that minors disclose regarding abuse, illegal activities, social dangers or abortion may
be disclosed to parents or other appropriate authorities if the counselor believes such disclosures
will enhance the counseling process or provide necessary protection for the minor.
4. The information may be disclosed to my spouse, if the counselor believes that this may strengthen the
marriage relationship or correct a misunderstanding in the mind of my spouse.
5. The information may be disclosed to other counselors representing CLM, as part of the normal
assistance counselors give to each other to enhance their effectiveness.
If you have read, understand, and agree to all of the above statements - your name in the box below will serve as your signature: (If client is a minor, please sign as the parent/guardian)
