Counseling Informed Consent Form

The Undersigned, having sought Biblical counseling as offered by Illuminate Community Church (ICC), a nonprofit religious organization, acknowledges their understanding of the following conditions and further releases from liability ICC, it’s agents or employees, from any claim arising from the undersigned’s participation in the above mentioned Biblical counseling ministry, as follows.

Name *
1) The counselee understands that counseling will be provided by Biblical counselors, not licensed counselors.
2) All counseling is provided in accordance with Biblical principles, and is not necessarily provided in adherence with any local or national psychological or psychiatric association.
3) Your confidentiality will be guarded at all times. However, counselees need to be aware that there are some situations in which their counselor may be required by Arizona law to report information to the proper authorities without the counselee’s permission or knowledge. These situations included, but may not be limited to a counselee’s indications of bodily harm to others, suicidal intentions, and reasonable belief of child abuse, elder abuse or neglect, or abuse of a vulnerable adult. (A.R.S.13-3620) If any of these occur, the proper authorities will be notified. Your counselor may also choose to consult with the ICC counseling ministry supervisor for counsel and advice as needed.
4) The Biblical counseling ministry of ICC is a non-profit, church-based ministry. In accordance with I Corinthians 6 and other passages, we require anyone receiving counseling from ICC, to agree to release ICC, its pastors, its counselors, agents and employees from liability. Your signature below is acknowledgement of this release.