A word from me:
Beacon Faith and Family (BFF) is a Christian Counseling Service. This means that I, the counselor, am a Bible believing Christian. This means I will be operating from a Christian perspective or frame of
reference. I will not put my beliefs on you or make you agree with me. I will most likely invite you to
explore your own spirituality and how it relates to whatever brings you to counseling. I will always do so, with you as an active participant and in the spirit of exploration. I will not judge you or ask you to participate in activities you are not comfortable with (such as prayer, scripture reading or other spiritual disciplines). The counselee does not have to be a Christian to participate in counseling.
I understand that I am entering into a counseling relationship with BFF.
I understand that my participation is voluntary and I may terminate at any time.
I understand that my counselor requests that I notify her in advance if I wish to discontinue counseling, so follow up, referral or closure can be done,
I understand the fee for service and agree to make payments as agreed upon below:
Payment is due cash or credit card at the beginning of the session.
__ $35 per session ___$105 per month (4 sessions) ___$95 (3 per month)
I understand that my personal information and even my participation in counseling with BFF is
confidential with the following exceptions: current suicidal or homicidal intent, sexual abuse of a minor or elderly person.
I understand that even though BFF is associated with Light Up The Dark, my counseling records,
participation and payments are kept separate and confidential from Light Up the Dark.
I understand that if I must sign a release of information if I want my counselor to disclose information about me to anyone and that this release can be cancelled at any time.
I understand that this is a ministry based, NOT a licensed mental health counseling practice. If I require psychological or psychiatric treatment an appropriate referral will be made.
I understand that I will not receive a clinical diagnosis or psychiatric evaluation from BFF and if I need or want these services a referral will be made.
I understand that if I need assistance after hours I can contact my counselor. If she is unavailable and if it is an emergency, I agree to contact 911 or the appropriate emergency services. I understand that my counselor will contact me at her earliest ability.
My signature attests that I have read and agree to the statements above and have had any questions I might have clarified.
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Signature of Client Date
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Witness Date
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