Welcome to the Grace Community Church People Help Counseling Center (PHCC). This is a church-based ministry that provides lay counseling. PHCC is a no-fee, short-term (8-10 sessions), biblical counseling facility. Counselees seen here will be considered “counselees of the agency.” We offer counseling to individuals or couples seeking a biblical perspective on the issues of life. We require anyone receiving counseling from PHCC to read and sign this informed consent. Finally, you have a right to obtain a copy of this form.
All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your written permission, except where disclosure is required by law. Most of the provisions explaining when the law requires disclosure were described to you in the notice of privacy practices that you received with this form.
When Disclosure is Required by Law.
Some of the circumstances where disclosure is required by the law are: where there is a reasonable suspicion of: (1) child, dependent, or elder abuse or neglect; (2) and where a Counselee presents a danger to self, to others, to property; (3) or is gravely disabled (for more details see also notice of privacy practices form).
When Disclosure May Be Required.
Disclosure may be required pursuant to a legal proceeding. If you place your mental status at issue in litigation initiated by you, the defendant may have the right to obtain the Counseling records and/or testimony by your counselor. In couple and family counseling, or when different family members are seen individually, confidentiality and privilege do not apply between the couple or among family members. Your counselor will use clinical judgment when revealing such information. Your counselor will not release records to any outside party unless so authorized to do so by all adult family members who were part of the treatment.
If there is an emergency during our work together, or in the future after termination, where your counselor becomes concerned about your personal safety, the possibility of you injuring someone else, or about you receiving proper psychiatric care, s/he will do whatever s/he can within the limits of the law to prevent you from injuring yourself or others and to ensure that you receive the proper medical care. For this purpose, s/he may also contact the police, hospital, or the person whose name you have provided on the biographical sheet.
Confidentiality of E-mail, Cell Phone, and Fax Communication.
It is important to be aware that e-mail and any cell phone or cordless phone communication, including text messaging, can be rather easily accessed by unauthorized people and, hence, the privacy and confidentiality of such communication can be easily compromised. E-mails, in particular, are vulnerable to such unauthorized access because servers have unlimited and direct access to all e-mails passing through them. Faxes can be sent erroneously to the wrong address. Please notify your counselor at the beginning of treatment if you decide to avoid or limit in any way the use of any or all of the above-mentioned communication devices. While reasonable backup, security, and other safeguards are in place, there is always some risk of inadvertent disclosure of information that comes with using these tools. By signing this informed consent, you agree to accept the risk of disclosure that comes with the use of these tools. Please do not use e-mail or fax in emergency situations.
Due to the nature of the Counseling process and the fact that it often involves making a full disclosure with regard to many matters that may be of a confidential nature, it is agreed that should there be legal proceedings (such as, but not limited to, divorce and custody disputes, injuries, lawsuits, etc.), neither you, your attorney, nor anyone else acting on your behalf will call on your counselor to testify in court or at any other proceeding, nor will a disclosure of the Counseling records be requested. We do not offer custody, psychiatric, or psychological evaluations. Recording of counseling appointments is strictly forbidden.
In addition, you, the counselee sought biblical counseling as such adhered to by Grace Community Church, a non-profit religious organization. You, as the Counselee hereby acknowledge your understanding of the following condition and further release from liability Grace Community Church, its agents or employees, from any claim arising from the undersigned participation in the above mentioned biblical counseling program, the same being identified as follows:
This is a church-based ministry providing counseling which supports spiritual, emotional, and mental health. The counseling center is part of a non-profit ministry. In accordance with I Corinthians 6 and other passages, we require anyone receiving counseling from GCC to agree to release GCC, its pastors, agents, employees, counseling supervisor(s), and lay counselors from liability. Your signature at the end of this form is your agreement to these conditions.
Your Counselor consults regularly with other professionals regarding his/her Counselees; however, the Counselee’s name or other identifying information is never mentioned. The Counselee’s identity remains completely anonymous, and confidentiality is fully maintained. Considering all of the above exclusions, if it is still appropriate, upon your request, your Counselor will release information to any agency/person you specify unless he/she concludes that releasing such information might be harmful in any way.
Telephone and Emergency Procedures.
If you need to contact your Counselor between sessions, please call Nancy Shippy at 480-829-0130. You will need to leave a message via voice mail. Your call will be returned as soon as possible. GCCCC is not a crisis center. If an emergency situation arises, please hang up and call the Police (911). If you need to talk to someone right away, you can call one of the following 24-hour crisis lines:
Empact at 480-784-1500
MMIC Crisis Line at 1-800-564-5465
Crisis Response Network at 602-222-9444
The Process of Counseling/Evaluation.
Our counseling method of practice is to integrate helpful psychological concepts with Scripture to offer a Cognitive-Biblical approach to counseling. At the conclusion of the intake session, your counselor will discuss treatment options with you; which may include assignment to a Lay Counselor, a professional volunteer or an outside referral (fee required).
Your emotional, mental, and spiritual wellbeing are of utmost importance to the PHCC. Participation in counseling can result in a number of benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek counseling. Working toward these benefits, however, requires effort on your part. Counseling requires your very active involvement, honesty, and openness in order to change your thoughts, feelings, and/or behavior. During evaluation or counseling, remembering or talking about unpleasant events, feelings, or thoughts can result in your experiencing considerable discomfort or strong negative feelings. This is uncomfortable, but a natural part of the counseling process and often provides the basis for positive change and personal decisions. Sometimes a decision that is positive for one family member is viewed quite negatively by another family member. Change will sometimes be easy and swift, but more often it will be slow and even frustrating. There is no guarantee that counseling will yield positive or intended results. A variety of counseling approaches may be helpful for you. However, you have a right to participate in treatment decisions and in the development and periodic review and revision of your treatment plan. You also have the right to refuse any recommended treatment or to withdraw informed consent to treatment. You and your counselor need to discuss the potential consequences of such refusal or withdrawal. Feel free to discuss at any time the treatment goals, procedures, or your impressions of the services that are being provided.
Since scheduling of an appointment involves the reservation of time specifically for you, a minimum of 24 hours notice is required for rescheduling or canceling an appointment. Not providing 24 hours notice would constitute a “no-show.” A no-show will count against the 10 sessions. On the third (3rd) no-show, therapy will be terminated. Additionally, there is no child or pet care available during your scheduled appointment times.
I have read the above agreement and office policies and general information carefully. I understand them and agree to comply with them:
Counselee name (print) Date Signature
Counselee name (print) Date Signature
Counselor Date Signature