Roots by the River Counseling                                          Personal Consent Form

A major aspect of the counseling relationship involves making clear the rights and responsibilities we share. Counselors are required to provide this information to their clients. It is important that you read the following information carefully, return one signed copy to me for my files, and keep the additional copy for yourself.

Professional Qualifications

I possess 18 years of pastoral counseling in Idaho Falls.  I have worked with children, adolescents, and adults in a variety of settings.

Counseling Philosophy

My 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.  It is my desire to pray for you in all counseling sessions.

Appointments

An individual counseling session is 50 minutes in length. The time and frequency of our counseling sessions will be arranged by mutual agreement.

Cancellations

Cancellations must be made at least 24 hours in advance.

Fees

Currently, there is no fee for any 50-minute individual counseling session. At this time, I do not work with insurance companies or manage care companies. I am not a licensed professional counselor in the state of Idaho.

Statement of Confidentiality

All of our communication becomes part of the counseling record, which is accessible to you upon request.  I will keep confidential anything you say as part of our counseling relationship, with the following exceptions:  (a) you direct me in writing to disclose information to someone else, (b) it is determined you are a danger to yourself or others (including child or elder abuse), or (c) I am ordered by a court to disclose information.  Any release of confidential information will be discussed with you.

For your benefit, and for my professional growth, I may sometimes seek consultation with other professionals regarding my work. I will carefully avoid disclosing your identity if I seek consultation regarding my work with you.

Client Consent to Treatment

___________________________________________                       _____________________

Client Name (Print)                                                                             Date

___________________________________________                       _____________________

Client Signature                                                                                  Date

___________________________________________                       _____________________

Parent/Guardian Name (Print)                                                         Date

___________________________________________                       _____________________

Parent/Guardian Signature                                                 Date

___________________________________________                       _____________________

Counselor                                                                                             Date

Note: Please sign the form indicating that you attest to the following and make a copy of the signed form for your personal records:

• I agree to the stated terms of this disclosure statement.
• I have read the above information and clarified any questions I have.