Informed Consent Form

Please read and agree to the following by signing your name below

The process of Christian counseling has many challenges to the sanctity and assurance of confidential and private information and the roles and relationships of the counselees and the counselor.

This form acknowledges that you, the counselee understand these challenges. 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 counseling 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 outside the counseling office, the counselor may be required by law to break confidentiality and make a report or call respective authorities.
  • If a counselee expresses clear and specific suicidal intent, the counselor may take reasonable measures for the safety of counselee. Reasonable measures may include notifying police if the counselee will not cooperate to involve him or herself in a watch-care program or facility.
  • If Counselor becomes aware of any other criminal activity Counselee is engaged in and Counselee refuses to bring to the appropriate authorities.

The purpose of this counseling is to provide counseling as religious guidance and non-professional guidance (consultation) about next steps by referring religious or professional services or resources. The ultimate goal of this counsel and consultation is the spiritual and psychological well-being of the client in accord with the statement of faith.

The Bible is a primary source for this counseling and assumed to be authoritative for faith and practice, though not an exhaustive source for psychological and physiological knowledge. Other sources will also be referenced and considered.

The counseling provided is non-licensed Christian counseling provided by a pastoral counselor whose primary credentials are in biblical and theological studies (BA, MA, MDiv, STM, PhD, Trinity Evangelical Divinity School).

The purpose of this counseling is to consult with the client about the next steps in recovery for a minimum of one session and a maximum of four sessions. The counselor reserves the right to extend this maximum limit if the situation should require it.

The counselor has the right to refuse any specific form of counseling you may request if he believes it is not in your best interest, or if he does not feel that his training qualifies his to provide it. The counselor has the right to terminate counseling with you, and make appropriate referrals to other resources if they believe that you are not benefiting from his care. If this happens they will only do so after conversations between you and your counselor.

The counselor is not providing legal, tax, financial, medical, or other technical or professional advice and the counselor undertakes no duty to recognize or opine when such advice is actually needed, and the parties further agree that no fiduciary or professional client relationship is being created between the counselor and the counselee as a result of this relationship. While the counselee may provide renumeration for the ministerial services provided pursuant to this agreement, such renumeration does not change this relationship from a religious to a “professional” or “fiduciary” relationship.

There shall be no legal or other liability that attaches to the counselor or any related institution or person for any advice, methods, conduct, or any act or omission related in any way to the service that is provided, and the counselee acknowledges that the counselee is 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.

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.

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.

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.

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 and guidance from Matthew A. LaPine under the terms listed above. 

Informed Consent Form
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