Informed Consent Form

(Lay Counselor)

having sought guidance through the Internship Program, hereby acknowledge the following conditions and further release of liability, Temple Church, its agents, volunteers or employees, from any claim arising from my participation in its Lay Counseling ministry.

The Lay Counselor is a person trained to listen and care for others.  Lay counselors are paraprofessionals (in other words, we are not licensed, paid professional therapists).  As Lay Counselors we are trained in the skills of listening, clarifying, and goal setting.  Our training and our counseling is supervised by the Hope Network Director.  We offer a response to your personal or family needs based on the Christian understanding of giving ourselves to our neighbors.

I understand that all information discussed during counseling sessions will be handled responsibly.  The Lay Counseling volunteers will consult when necessary with the Lay Counseling staff member as a part of my spiritual and personal care.  No information revealed in any session is discussed outside the session with the following exceptions:
  • Supervision by the Hope Network Director or pastoral staff
  • Legally and / or ethically mandated reporting to appropriate authorities:
1) if I reveal any threats or acts of serious harm to myself or others, or
2) if I reveal anything that constitutes evidence of suspected neglect,    
 physical, or sexual abuse of children or maltreatment of vulnerable adults;
3) if mandated by a court of law.
  • Release of information to a professional counselor or counseling agency upon my written consent.
There is no fee for your counseling but if you would like to make a donation, you can make the check out to Temple Church and put HOPE Network in the memo or you can pay cash.

Out of courtesy for my counselor, I will give at least 24 hours prior notice before cancelling an appointment.

I have reviewed the above conditions with my counselor and have agreed to the terms set above.