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Informed Consent And Counseling Agreement Form

The Pastoral Care Ministry of The Chapel offers counseling to provide biblical spiritual care, support, encouragement, and referrals when determined necessary in a safe and confidential manner. Support is typically on a short-term basis during times of significant need or crisis to help bring clarity to the issues involved and define the priorities of care. After this initial care, ongoing discipleship/mentorship can be considered. The volunteer lay counselors are trained and under the direction and general supervision of the Pastoral Care Team Leader and the Biblical Counseling Director at The Chapel. Regardless of their education, training, licensure, or expertise, The Chapel's lay counselors do not function in a professional role and do not provide clinically oriented mental health treatment or therapy.


All communications, records, and contacts with The Chapel's lay counselors will be held in strict confidence. Information may be released in accordance with the laws of New York only when

1. The care seeker and/or guardian (if care seeker is under 18 years of age) signs a written release of information indicating informed consent to such release ; or

2. The care seeker expresses serious intent to harm himself/herself or someone else; or

3. There is evidence or reasonable suspicion of abuse against a minor child, elder person (65 years or older) or a dependant adult; or

4. There is evidence demonstrating a gross distortion of reality or the ability to function in normal daily routines; or

5. The Chapel's lay counselor feels that counsel, assistance, and/or supervision may be required from the Pastoral Care Team Leader or Biblical Counseling Director.

Counseling Agreement

Assignments/Accountability: Counselees make more rapid progress when they are required to study or to perform specific informational or behavioral assignments which pertain to the problem. We tailor these assignments to the individual counselee and the circumstances. We are not interested in wasting the time of the counselors or the counselee. We are interested in helping people learn how to experience the peace and joy that result from a walk of thankful obedience to God's Word, and we hold the counselees accountable for doing the assignments on schedule.

How much does it cost? The Chapel's Counseling Ministry is available at no cost for those who attend one service a week at The Chapel (or other Bible-believing church).


  1. I will keep the appointment time, or will call to cancel in advance with a legitimate reason. 
  2. I will fulfill any assignments.
  3. I will attend The Chapel (or other Bible-believing church) each week while I am receiving counseling. If from another church, we must receive the pastor's acknowledgement.
  4. I understand that confidentiality cannot be guaranteed in the case of information as indicated above. 

I/we, the undersigned care seeker(s) or guardian(s), have read, fully understand, and agree to the conditions of this Informed Consent and Counseling Agreement Form and acknowledge that by signing below.

The Chapel is on mission to reach every Man, Woman & Child with repeated opportunities to hear and see the Gospel of Jesus Christ.