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Christian Counseling Service CLIENT INFORMATION FORM The Christian Counseling Service is committed to offer those who come for counseling competent and quality service. Clients of this service have the right to information regarding confidentiality, available hours, fees, your therapist's credentials, methods, and limits in therapy. The Christian Counseling Service is a ministry of Madison Park Christian Church in Quincy, Illinois. The ministry is based on Biblical truths and Christian values. While we do not intend to impose our beliefs on others, we do consider the importance and place of the spiritual, as well as the physical, social, and psychological aspects of people. We are committed to all who come to us, regardless of age, gender, race, disability, or religious affiliation. We strive to keep our practice consistent with Biblical teachings as well as with state and professional standards and codes of ethics. Please read this information and feel free to ask any questions. Please sign and date in the places provided, signifying your understanding and agreement to the terms of our service. Confidentiality The counseling you receive from the Christian Counseling Service of Madison Park Christian Church will be offered with the utmost professional regard. The content of counseling sessions will not be disclosed to anyone without written and signed consent. In the case of marital and family counseling, all responsible parties must give signed consent. However, I cannot guarantee confidentiality among participants (e.g., from individual sessions) in the process of therapy; I reserve the right to use my discretion in such cases. State regulations and ethical codes do mandate, however, that confidentiality be broken if one or more of the following situations exist:
Hours and Fees Generally, times available for appointments include Monday - 1:00 p.m. to 4:00 p.m.; Tuesday and Thursday - 9:00 a.m. to 4:00 p.m.; and Tuesday evening - 6:30 to 8:30 and Wednesday - 9:00 a.m. to 11:00 a.m. Arrangements for other appointment times may be possible. Sessions typically last one hour. Madison Park Christian Church provides the counseling service as a ministry of the congregation and, as such, there are no fees charged to those who attend. For those who do not attend Madison Park Christian Church, a sliding scale fee will be charged. There will also be a fee charged to all clients to cover materials for assessment tools such as the Taylor-Johnson Temperament Analysis and the Myers-Briggs Type Indicator. The fee is $5.00 per person per tool. Credentials
Methods I have received training in a variety of
methods and techniques. Much of my training has been in family systems
theory and therapy. I have also received training in solution focused
therapy. A descriptive phrase to speak of the approach used here is a
solution based therapy with a systemic perspective. However, other techniques
may be used which might be determined to be more effective for you. Length
of treatment is difficult to predict, however solution focused therapy
is a brief therapy model. You may discuss your treatment at any time with
me. You may also seek a second opinion and/or terminate the counseling
at any time. ********************************************************************************* I have read the preceding information and understand the conditions and read and agree to receive counseling under these conditions. ____________________________________________ Date___________________________ ____________________________________________ Therapist's name: Evan W. Horner |