Informed Consent Form
Please read and agree to the following by signing your name below
The purpose of these meetings is to provide religious and non-professional transitional counseling to assess the client’s situation and discuss the next steps in recovery including but not limited to referring the client to religious or professional services or resources, The ultimate goal of this transitional counseling is the spiritual and psychological well-being of the client in accord with the statement of faith (see below). The counseling is limited to a minimum of one session and a maximum of four sessions, continuance by mutual agreement between client and counselor. The counselor reserves the right to extend this maximum limit if the situation should require it.
The fee for each session is $120 USD.
Confidentiality means that the counselor has a responsibility to safeguard information obtained during sessions. It is important that you understand all identifying personal information about you is kept confidential, except as noted below. In order to protect your confidentiality, you must sign a release of information before any information about you is given to any outside parties.
This form acknowledges that you, the client understand the exceptions to confidentiality. By signing the below, you are demonstrating clear agreement to the conditions surrounding counseling, the roles of the respected parties, and the responsibilities of all concerned.
I understand that information in the session is confidential, and that no person can have access to it other than those to whom I have given expressed written permission. Exceptions to this are:
- If there are situations of child abuse, vulnerable adult abuse or threats of harm to people, the counselor may be required by law to break confidentiality and make a report or call respective authorities.
- If a client expresses clear and specific suicidal intent, the counselor may take reasonable measures for the safety of client. Reasonable measures may include notifying police if the client will not cooperate to involve him or herself in a watch-care program or facility.
- If counselor becomes aware of any other criminal activity client is engaged in and client refuses to bring to the appropriate authorities.
The counseling provided is non-licensed Christian counseling provided by a counselor whose primary credentials are in biblical and theological studies (BA, MA, MDiv, STM, PhD). His doctorate from Trinity Evangelical Divinity School in Systematic Theology, dissertation published as The Logic of the Body (Lexham, 2020). This work is interdisciplinary work in integrating theology with psychology. In addition, he has taught “Theological Foundations of Counseling” at Reformed Theological Seminary (December of 2022).
The counselor has the right to refuse any specific form of counseling the client may request if he believes it is not in the client’s best interest, or if he does not feel that his training qualifies him to provide it. The counselor has the right to terminate counseling with the client, and make appropriate referrals to other resources if he believes that the client is not benefiting. If this happens he will only do so after dialogue with the client. In addition to psychological and therapeutic resources and practices, the Bible is a primary source for this consulting and assumed to be authoritative for faith and practice.
The counselor is not providing legal, tax, financial, medical, or other technical or professional advice, so the counselor undertakes no duty to recognize or opine when such advice is actually needed. Counselor and client further agree that no fiduciary or professional client relationship is being created between the counselor and the client as a result of this relationship. While the client may provide renumeration for the counseling services provided pursuant to this agreement, such renumeration does not change this relationship from a religious to a “professional” or “fiduciary” relationship.
The client waives any legal or other liability to the consultant for any advice, methods, or any act or omission related in any way to the service that is provided, and the client acknowledges that they are voluntarily seeking this counsel (free from coercion, duress, or pressure) with a full understanding of the nature, purpose, and effect of this agreement.
Statement from Trinity Evangelical Divinity School
We believe in one God, Creator of all things, holy, infinitely perfect, and eternally existing in a loving unity of three equally divine Persons: the Father, the Son and the Holy Spirit. Having limitless knowledge and sovereign power, God has graciously purposed from eternity to redeem a people for Himself and to make all things new for His own glory.
We believe that God has spoken in the Scriptures, both Old and New Testaments, through the words of human authors. As the verbally inspired Word of God, the Bible is without error in the original writings, the complete revelation of His will for salvation, and the ultimate authority by which every realm of human knowledge and endeavor should be judged. Therefore, it is to be believed in all that it teaches, obeyed in all that it requires, and trusted in all that it promises.
THE HUMAN CONDITION
We believe that God created Adam and Eve in His image, but they sinned when tempted by Satan. In union with Adam, human beings are sinners by nature and by choice, alienated from God, and under His wrath. Only through God’s saving work in Jesus Christ can we be rescued, reconciled and renewed.
We believe that Jesus Christ is God incarnate, fully God and fully man, one Person in two natures. Jesus—Israel’s promised Messiah—was conceived through the Holy Spirit and born of the virgin Mary. He lived a sinless life, was crucified under Pontius Pilate, arose bodily from the dead, ascended into heaven and sits at the right hand of God the Father as our High Priest and Advocate.
THE WORK OF CHRIST
We believe that Jesus Christ, as our representative and substitute, shed His blood on the cross as the perfect, all-sufficient sacrifice for our sins. His atoning death and victorious resurrection constitute the only ground for salvation.
THE HOLY SPIRIT
We believe that the Holy Spirit, in all that He does, glorifies the Lord Jesus Christ. He convicts the world of its guilt. He regenerates sinners, and in Him they are baptized into union with Christ and adopted as heirs in the family of God. He also indwells, illuminates, guides, equips and empowers believers for Christ-like living and service.
We believe that the true church comprises all who have been justified by God’s grace through faith alone in Christ alone. They are united by the Holy Spirit in the body of Christ, of which He is the Head. The true church is manifest in local churches, whose membership should be composed only of believers. The Lord Jesus mandated two ordinances, baptism and the Lord’s Supper, which visibly and tangibly express the gospel. Though they are not the means of salvation, when celebrated by the church in genuine faith, these ordinances confirm and nourish the believer.
We believe that God’s justifying grace must not be separated from His sanctifying power and purpose. God commands us to love Him supremely and others sacrificially, and to live out our faith with care for one another, compassion toward the poor and justice for the oppressed. With God’s Word, the Spirit’s power, and fervent prayer in Christ’s name, we are to combat the spiritual forces of evil. In obedience to Christ’s commission, we are to make disciples among all people, always bearing witness to the gospel in word and deed.
We believe in the personal, bodily and glorious return of our Lord Jesus Christ. The coming of Christ, at a time known only to God, demands constant expectancy and, as our blessed hope, motivates the believer to godly living, sacrificial service and energetic mission.
RESPONSE AND ETERNAL DESTINY
We believe that God commands everyone everywhere to believe the gospel by turning to Him in repentance and receiving the Lord Jesus Christ. We believe that God will raise the dead bodily and judge the world, assigning the unbeliever to condemnation and eternal conscious punishment and the believer to eternal blessedness and joy with the Lord in the new heaven and the new earth, to the praise of His glorious grace. Amen.
By signing below, I agree to receive counseling from Matthew A. LaPine, PhD under the terms listed above.