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CHRISTIAN COUNSELING & WELLNESS CONSENT FORM

A. CHRISTIAN COUNSELING & WELLNESS EXPECTATIONS

Counseling Services:

Our Biblical, Christian, Faith-Based, or Pastoral counseling centers on the Lord Jesus Christ. This type of counseling includes listening, teaching, encouraging, comforting, and guiding clients to a deeper relationship with Jesus Christ, Spirit-led inner transformation, and wisdom on approaching relationships, addictions, finances, behavior, career, and lifestyle. 

Wellness Services:

In addition to Christian counseling, we offer wellness services that promote overall body, mind, and spirit health. Our wellness specialists use evidence-based approaches, including:

  • Nutritional Guidance – Assisting clients with healthy eating habits to support physical and mental well-being.

  • Stress Management – Teaching relaxation techniques, breathing exercises, and faith-based mindfulness.

  • Physical Wellness Coaching – Encouraging movement, exercise, and healthy lifestyle habits.

  • Holistic Wellness Therapies – Including essential oils, guided prayer meditation, and other complementary wellness techniques.

Our wellness specialists are not medical doctors and do not diagnose or treat medical conditions. They provide guidance based on scientific research, biblical principles, and holistic practices to enhance well-being. We can refer you to physicians in our wider Christian Health Network.

Our counseling and wellness approach considers various therapy and physical care models that align with Biblical wisdom and truths. Learn more about our Approach and Doctrinal positions.

Ultimately we aim to glorify God and help you reflect His grace and joy. As Scripture says:

“He is the one we proclaim, admonishing and teaching everyone with all wisdom, so that we may present everyone fully mature in Christ” (Colossians 1:28-29, NIV).

“To equip his people for works of service, so that the body of Christ may be built up until we all reach unity in the faith and the knowledge of the Son of God and become mature” (Ephesians 4:12-13, NIV).

Referrals to Professionals:

If your issues require legal, medical, or other professional expertise, we encourage you to seek help from independent professionals. Our Christian counselors and wellness specialists will work alongside these advisors to provide spiritual and holistic support. We have a network of trusted providers we can refer you to.

Intent Listening:

We encourage open communication so that your thoughts, worries, and concerns can be understood clearly, allowing for a tailored and compassionate counseling or wellness experience.

Assignments:

Personalized assignments help you progress more quickly. They are designed to give insight and promote spiritual growth between sessions.

Accountability:

We aim to help you grow in faith and glorify God. We encourage active participation in counseling sessions, wellness programs, and any exercises assigned between sessions to achieve this.

Length of Counseling & Wellness Sessions:

The number of sessions varies depending on the complexity of the issue and your engagement in the process. Some issues may be resolved quickly, while more complex problems, like marriage, addiction counseling, or wellness coaching, may require longer or more sessions.

B. CHRISTIAN COUNSELING & WELLNESS AGREEMENT

Biblical Counseling:

I (We) understand that the counseling and wellness services will be based on biblical principles intended to glorify God and promote a Spirit-filled life.

Appointments and Cancellations:

I (We) will honor our scheduled appointments or provide at least 72 hours notice to cancel. I will be charged for the session if I cancel less than 72 hours before or do not show up.

Confidentiality & Federal Patient Privacy Regulations:

Confidentiality is central to counseling and wellness services. However, if there is a risk of harm to myself or others, or if required by law, my counselor or wellness specialist may share relevant information with appropriate authorities or individuals.

The federal government considers Protected Health Information (PHI) to include:

  • Name, address, and contact information

  • Health history and wellness plans

  • Session notes and recommendations

  • Any payment information related to services received

HIPAA Compliance & Session Notes: We use secure companies and software, such as Google Workspace / Google Meet, Fireflies.ai, Impact Family CRM, etc., to securely store and share session notes. All data is protected with two-factor authentication. Before emailing notes, we require your written consent to inform you of any potential risks associated with email communications (e.g., privacy breaches if not encrypted).

Cameras and Recordings:

We may record customer service and counseling/coaching sessions conducted in-person or virtually for quality assurance, notes and security. Recordings are stored securely and can be shared with clients or deleted upon written request to our support team.

Legal Responsibility:

I (We) will not hold Impact Family Inc. or its affiliated counselors and wellness specialists legally liable for advice provided during counseling or wellness sessions. I understand their role is to help me seek and understand God’s will, and I agree to resolve any disputes through Christian mediation services.

Legal Proceedings:

I (We) agree not to subpoena any counselor or wellness specialist or their notes for legal proceedings regarding matters discussed during counseling or wellness sessions.

Follow the Terms and Conditions:

I (We) agree to adhere to all the terms and conditions: www.impact.vision/terms.

C. CONTRIBUTION AMOUNT

We depend on the generous contributions of our counselees and partners. If you cannot meet the suggested amount, please discuss this with our team or apply for a scholarship.

Suggested donations:

  • $90 per 50 minutes for new and existing clients

  • $90–$150 per 2-8 hour workshops and group sessions

Please inquire about becoming a financial and prayer sponsor to support other individuals, couples, or families. You can also give one-time or recurring funds at www.impact.vision/donate. All contributions are tax-exempt.

D. PAYMENT DISPUTES

In the event of a payment dispute, I consent to Impact Family submitting redacted session notes to the involved merchant services or financial institutions to assist in resolving the dispute. This submission will include only the information necessary for verifying the session details, and intimate or sensitive details of the counseling or wellness sessions will be protected and excluded from the provided documentation. This measure supports transparent and fair resolution while maintaining client confidentiality to the highest degree.

E. CHILDCARE POLICY

Unfortunately, we do not provide childcare. If you must bring a child, please ensure the issues discussed in counseling or wellness sessions are appropriate for their presence.

F. CANCELLATION, RESCHEDULING & REFUNDS

Cancellation:

You are entitled to a full refund if you cancel 72 hours before your appointment. Cancellations can be made through your client portal. View tutorial.

No-Show Refund:

If your counselor or wellness specialist does not attend within 15 minutes of your scheduled time, you are entitled to a full refund.

Medical Emergencies:

If a verified medical emergency prevents attendance, we will issue a coupon to reschedule your session.

You can manage all scheduling and refunds through your client portal at www.impact.vision/calendar-client-portal.

CLIENT AGREEMENT

I have read and understood these terms. By signing below or contributing online, I agree to these conditions and consent to Christian counseling and wellness services as described.

Client Name: ______________________ Date: ________________

Electronic Signature Agreement

By signing your name below, you are signing this consent form electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form.

Electronic Signature: ______________________

Client Name: As inputted on the website
Date: As inputted on the website
Electronic Signature Agreement: As Inputted On Website

Archived as of 3/19/25

A. CHRISTIAN COUNSELING EXPECTATIONS

  1. Christian/Biblical Counseling: Biblical counseling, also called Christian or pastoral counseling, centers on the Lord Jesus Christ. This type of counseling includes listening, teaching, encouraging, comforting, and guiding clients to a deeper relationship with Jesus. Our goal is to glorify God and help you reflect His grace and joy in your life. As Scripture says:

    • “He is the one we proclaim, admonishing and teaching everyone with all wisdom, so that we may present everyone fully mature in Christ” (Colossians 1:28-29, NIV).
    • “To equip his people for works of service, so that the body of Christ may be built up until we all reach unity in the faith and in the knowledge of the Son of God and become mature” (Ephesians 4:12-13, NIV).

  2. Referrals to Professionals: If your issues require legal, medical, or other professional expertise, we encourage you to seek help from independent professionals. Our Christian counselors will work alongside these advisors to provide spiritual guidance from a biblical perspective.

  3. Intent Listening: We encourage open communication so that your thoughts, worries, and concerns can be understood clearly, allowing for a tailored and compassionate counseling experience.

  4. Assignments: Personalized assignments help you progress more quickly. They are designed to give insight and promote spiritual growth between sessions.

  5. Accountability: We aim to help you grow in faith and glorify God. To achieve this, we encourage active participation in counseling sessions and any exercises assigned between sessions.

  6. Length of Counseling: The number of sessions varies depending on the complexity of the issue and your engagement in the process. Some issues may be resolved quickly, while more complex problems, like marriage or addiction counseling, may require longer or more sessions.

B. CHRISTIAN COUNSELING AGREEMENT

  1. Biblical Counseling: I (We) understand that the counseling provided will be based on biblical principles and is intended to glorify God and promote a Spirit-filled life.

  2. Appointments and Cancellations: I (We) will honor our scheduled appointments or provide at least 72 hours' notice to cancel. If I cancel less than 72 hours before or do not show up, I will be charged for the session.

  3. Confidentiality: Confidentiality is central to counseling, but if there is a risk of harm to myself or others, or if required by law, my counselor may share relevant information with appropriate authorities or individuals.

  4. HIPAA Compliance & Session Notes: We use secured Company Google Workspace accounts with HIPAA compliance to share session notes. All data is stored securely with two-factor authentication. Before emailing any notes, we require your written consent, making you aware of any potential risks associated with email communications (e.g., breaches of privacy if not encrypted).

  5. Cameras and Recordings: For quality assurance and security, we may record sessions conducted via phone or webcam. Recordings are stored securely and can be deleted upon written request.

  6. Legal Responsibility: I (We) will not hold Impact Family Inc. or its affiliated counselors legally liable for advice provided during counseling. I understand their role is to help me seek and understand God’s will, and I agree to resolve any disputes through Christian mediation services.

  7. Legal Proceedings: I (We) agree not to subpoena any counselor or their notes for legal proceedings regarding matters discussed during counseling.

  8. Follow Terms and Conditions: I (We) agree to adhere to all the terms and conditions.

C. CHRISTIAN COUNSELING CONTRIBUTIONS

We depend on the generous contributions of our counselees and partners. If you cannot meet the suggested amount, please discuss this with our team or apply for a scholarship. Suggested donations:

  • $90–$150 for new client/intake sessions
  • $90–$150 for ongoing sessions

You can contribute online at www.impact.vision/donate.

D. CHILDCARE POLICY

Unfortunately, we do not provide childcare. If you must bring a child, please ensure the issues discussed in counseling are appropriate for their presence.

E. CANCELLATION, RESCHEDULING & REFUNDS

  1. Cancellation: If you cancel 72 hours before your appointment, you are entitled to a full refund. Cancellations can be made through your client portal. View tutorial.

  2. No-Show Refund: If your counselor does not attend within 15 minutes of your scheduled time, you are entitled to a full refund.

  3. Medical Emergencies: If a verified medical emergency prevents attendance, we will issue a coupon to reschedule your session.

You can manage all scheduling and refunds through your client portal at www.impact.vision.

CLIENT AGREEMENT

I have read and understood these terms. By signing below or contributing online, I agree to these conditions and consent to Christian counseling as described.

Client Name: As Inputted On the Website
Date: As Inputted On Website
Electronic Signature Agreement: As Inputted On Website

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