Informed Consent Form


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 Counseling Program.
The Intern is a person trained to listen and care for others under supervision of a licensed clinician. 
I understand that all information discussed during counseling sessions will be handled responsibly.  The Intern will consult when necessary with the Hope Network Director as needed to secure rooms.  The intern will be consulting the supervisor on my behalf to give me the best care possible.  No information revealed in any session is discussed outside the session with the following exceptions:
  • Intern Supervisor who is a licensed clinician.  This will be done in order to discuss how I can learn to help you best.
  • Hope Network Director if an issue arises on site that needs to be reported.
  • 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.