RELEASE OF LIABILITY AND CONFIDENTIALITY AGREEMENT FOR PASTORAL COUNSELING

I, __________________________________________, enter into this Agreement with Barbara’s Lighthouse, hereinafter referred to as The Love Church Charlotte, to confirm in this Agreement with conditions of my participation in pastoral counseling to be performed by the Pastors of The Love Church Charlotte.

I acknowledge that I have voluntarily agreed to participate and request pastoral counseling from the Pastors of The Love Church Charlotte and I enter into this agreement on my own free will.

I acknowledge that it is my responsibility to ascertain my own need for professional counseling or therapy and to seek such professional services, as needed. I am aware that my participation in pastoral counseling is not to be construed as a substitute for psychiatric treatment, psychotherapy, therapeutic counseling, or any other form of professional counseling or therapy.

I am voluntarily participating in pastoral counseling and I accept complete responsibility for my own psychological, mental, emotional, social, and spiritual well­being.

In consideration of my voluntary participation in pastoral counseling, I, on behalf of myself and my assigns, heirs, executors, guardians and other legal representatives release, discharge, waive and forever relinquish The Love Church Charlotte  (including its agents, employees, officers, directors, and any members of The Love Church Charlotte) from any and all claims, known or unknown, arising from or in any way connected with my participation or involvement in pastoral counseling including but not limited to, any information provided to me or statements made during such pastoral counseling.

Further, I, on behalf of myself and my assigns, heirs, executors, guardians and other legal representatives, release, discharge, waive, and forever relinquish any actions or causes of action whatsoever which may later arise, and I agree that under no circumstances will I or my assigns, heirs, executors, guardians and other legal representatives, prosecute or present any claims against, sue or seek to attach the property of The Love Church Charlotte including (The Love Church Charlotte’s agents, employees, officers, and directors and any other members of the The Love Church Charlotte staff) and that I waive all actions, claims, or demands that I now or hereafter may have, for any injuries suffered by me during my participation or involvement in pastoral counseling, resulting from any acts or omissions by The Love Church Charlotte or any of its agents, employees, officers or directors or resulting from the acts or omissions of any other participant in pastoral counseling.

I, for myself, and my assigns, heirs, executors, guardians and other legal representatives, hereby agree that in the event any claim for damages shall be prosecuted against The Love Church Charlotte (or its agents, employees, officers, and directors or any other members of The Love Church Charlotte staff) as a result of my acts or omissions, that I, or my estate, shall indemnify and save harmless The Love Church Charlotte’s staff its agents, employees, officers, and directors or any other members of the Church staff, from any and all claims or causes of action by whomever and wherever made or presented for damages including the cost and expense of defending the same.

I UNDERSTAND AND AGREE THAT THIS RELEASE AND WAIVER OF LIABILITY CONSTITUTES A COMPLETE WAIVER OF MY RIGHT TO SUE AND COLLECT DAMAGES FROM THE LOVE CHURCH CHARLOTTE INCLUDING ITS AGENTS, EMPLOYEES, OFFICERS, AND DIRECTORS OR ANY OTHER MEMBER OF THE LOVE CHURCH CHARLOTTE’S STAFF) REGARDLESS OF WHETHER THE LOVE CHURCH CHARLOTTE  (INCLUDING ITS AGENTS, EMPLOYEES, OFFICERS, AND DIRECTORS, OR ANY OTHER MEMBER OF THE LOVE CHURCH CHARLOTTE  STAFF) ACTED NEGLIGENTLY.

I further acknowledge and understand that any informal information provided during pastoral counseling or any other statement made during the counseling session (s) shall be considered confidential and shall not be disclosed except as required by law.

If any portion of this release of liability agreement declared invalid or unenforceable by a final judgment of a court of competent jurisdiction, I hereby agree that such determination shall not affect the balance of this release as liability agreement, but this release of liability agreement shall remain in full force and effect, as such invalid portion shall be deemed severable,

I represent and warrant that I am at least eighteen (16) years of age and that I have carefully read this Agreement and fully understand its contents, terms and significance and understand the legal consequences of signing this Agreement.

I am aware that this Agreement contains a release of liability and a contract between The Love Church Charlotte and myself and I sign this Agreement of my own free will.

____________________________________________________________ Date Participant’s Name (Please Print)

____________________________________________________________ Date Participant’s Signature

____________________________________________________________ Date Representative from The Love Church Charlotte