THE HOPE CENTER-CHRISTIAN FAMILY CHAPEL OF JACKSONVILLE, FLORIDA, INC (“CHRISTIAN FAMILY CHAPEL”) AGREEMENT AND CONSENT TO COUNSEL

PLEASE READ THIS CONSENT CAREFULLY: You will be signing/acknowledging at the end to confirm that you understand and agree to it.

BIBLICAL COUNSELING: This is a ministry of the Gospel of Jesus Christ and is part of our practice of religion. You are voluntarily seeking religious guidance (biblical counseling) from one or more other Christians. The goal of biblical counseling is to help Christians become more and more like Jesus Christ in attitude, thought, and action. With that in mind, biblical counseling is the same as discipleship. As Christians, we are called to make disciples, teaching them to observe all that Jesus commanded (Matthew 28:16-20). Our goal in providing biblical counseling is to help you live your entire life in a God-pleasing/God-honoring way. This includes, but is not limited to, providing biblical counseling to assist you in meeting the challenges of your life; shedding sin that so easily entangles; learning to develop, cultivate, and live in relationships that please God; giving thanks to God in all circumstances; living in community of other believers as you participate in your local church, and learning to rely on the Holy Spirit for direction as you seek to know God through His Word (the Bible). Although the biblical counsel we provide is intended to be practical, it is entirely your decision how to (and whether to) implement that counsel. We want to help you love God and love others as we walk with you through this process. During the counseling relationship, we may counsel you from the Bible that certain conduct is sinful and must be stopped in order to please God, and we may counsel you in how the Bible directs Christians to put off that sin and, instead, to live a life characterized by self-control and godliness. By signing/acknowledging below, you are specifically agreeing to such counsel and are affirmatively asking that we provide it. As stated above, we will counsel you from our deeply held Christian, religious beliefs, and this counseling is part of our practice of religion. Biblical counseling is disciple-making and it in no way shall be construed as a sale of services. We do not charge for this counseling. We do, however, ask that you pay for any resources that are assigned as homework during the counseling.

BIBLICAL BASIS: We believe that the Holy Scriptures (the Bible) provide sufficient guidance and instruction for faith and life. Therefore, our counseling is based on biblical principles rather than those of secular psychology or psychiatry. We are not licensed or certified psychotherapists, psychologists, psychiatrists, mental health professionals, marriage and family therapists, or social workers, nor are we acting in such capacities. If you are unwilling to use the Bible as the final authority in counseling or are unwilling to do the homework assigned, you should not proceed with this counseling. However, we do want to help, and we pray you will decide to look to God’s Word for guidance as we follow the loving example of Jesus Christ. Through the power of the Holy Spirit, we believe your life can be transformed.

NO PROFESSIONAL ADVICE, ETC. We do not provide legal, tax, medical, investment, or other technical or professional advice (although we advise that you handle all matters in a Christlike and ethical way). Even though you are agreeing to participate in biblical counseling, there may be times when you need such professional advice. Although we undertake no duty to recognize when or if such advice is actually needed, if we are of the opinion that such professional counsel would be helpful, we may encourage you to seek it. Further, we are happy to cooperate with such advisors and help you to consider their counsel in light of relevant biblical principles.

You understand and agree that we are not responsible for, nor shall we be liable for any physical, mental or medical condition of any counselee, whether or not such condition is affected in any way by the counseling process or counsel provided.

No professional-client or fiduciary relationship is created between any counselee and counselor. The parties recognize that the counselor may have training in matters and/or employment beyond the scope of biblical counseling. However, the counselor is not acting in that other capacity on behalf of the counselee. Further, you understand and agree that Christian Family Chapel is not liable for the counsel provided. Although we may take into consideration any applicable laws that you bring to our attention, it is intended that the Bible shall be the supreme authority governing every aspect of the counseling process and that God’s glory is the ultimate goal. However, failure of the counselor to interpret or apply the Bible in any particular way shall not subject the counselor to liability or give rise to complaint by any party. There shall be no legal or other liability that attaches to any counselor or Christian Family Chapel for any advice provided, and you acknowledge that you are voluntarily seeking this counsel (free from coercion, duress or pressure).

CONFIDENTIALITY: Although confidentiality is often one aspect of the counseling process, and we intend to guard the information you entrust to us; absolute confidentiality is not biblical in all circumstances. There are a number of situations when it may be necessary (as determined by us in our sole discretion) for us to share information with others and/or to take protective measures. These may include situations (1) When we are uncertain how to address a particular problem and need to seek advice from another counselor, pastor, or elder; (2) when a counselee attends (or attended) another church, and we believe it is important to talk with his or her pastor, elders or others at that church in leadership; (3) when there is a clear indication that someone may be harmed unless others intervene or are consulted; (4) when a person refuses to renounce a particular sin and confess it to those impacted and it becomes necessary to seek the assistance of others in the church to encourage repentance, confession, and reconciliation (see Proverbs 15:22; 24:11; Matthew 18:15-20); (5) when a criminal activity has occurred and the counselee refuses to bring it to the attention of the authorities when there is a legal obligation to do so; (6) if we believe a person is in need of protective services or that a person of familial authority needs to be informed (e.g. wife/husband, or child/parent); (7) when required by law. Information also may be shared for education/training purposes (see below). Also, if you are a member/ attender of Christian Family Chapel, the fact you are receiving counseling may be shared with the Pastor-Teacher or Elder team to assist them in shepherding the flock. Additionally, should you seek financial assistance from Christian Family Chapel’s benevolence committee, relevant information may be shared by your counselor with the benevolence committee. Be assured that our counselors strongly prefer not to disclose personal information to others and will make every effort to help you find ways to resolve a problem as privately as possible. Nothing shall impose any obligation or legal duty on a counselor to disclose or maintain confidential any particular information.

ATTENDANCE AND WHAT TO BRING: Please bring with you (one for each person being counseled) a Bible (a literal translation such as NASB, ESV, NIV etc. rather than a paraphrase such as The Living Bible), looseleaf notebook, paper and pen. Please make every effort to attend every scheduled session. Out of respect for our counselors we require a $25 deposit which will be refunded to you should you keep all your appointments or cancel at least 48 hours in advance of your appointment. You will be asked to submit this deposit prior to or upon arrival at your counseling session. If you should ever cancel upon less than 48 hours’ notice, you would forfeit your cancellation fee. You would need to submit another $25.00 before continuing your counseling sessions. If you attend a church other than Christian Family Chapel, please encourage your pastor or someone in leadership at your church to accompany you in counseling sessions. In fact, depending on the situation, we may require such attendance as we recognize and respect the authority and the discipline of the local church in your spiritual life. In addition, this makes transfer back to the pastoral care of your church much easier to implement. If you are not attending a church, we will expect you to attend weekly worship services at Christian Family Chapel as part of the counseling you will receive.

EDUCATION AND TRAINING:? The Hope Center-Christian Family Chapel is also a training center for future counselors. Accordingly, to facilitate both counseling and training, you understand and agree that the counselor may have people assist or observe him/her in each counseling session. Such individuals will be subject to the same confidentiality provisions set forth above.

TERMINATION/RECORDS: At any time and for any reason, either the counselor or counselee may terminate counseling. However, termination of counseling will not preclude the counselor from making the disclosures set forth above in the paragraph titled “Confidentiality”, if deemed appropriate by the counselor or if compelled by other legal means. You agree that counseling sessions, in whole or in part, may be recorded by the counselor by writings, audio, or other nonelectronic or electronic means, and you consent to such recordings. Although it is understood that we may (but are not required to) keep records of sessions and their subject matter, it is expressly agreed that we may destroy any such records of any counseling sessions at any time that we deem appropriate, without incurring liability.

INDEMNITY AND RELEASE OF LIABILITY: You agree to hold harmless and release The Hope Center and Christian Family Chapel and their counselors, employees, volunteers, and agents from any and all past, present, future, known and unknown liability, actions, causes of actions, claims, expenses, damages, or injury that you may suffer as a direct or indirect result of any counseling services you receive. It is the specific intent and purpose of this legally binding document to release, discharge, and indemnify The Hope Center, Christian Family Chapel, and their counselors, employees, agents, and volunteers for any and all claims and causes of action of any kind or nature in connection with the biblical counseling service or any other associated activities. This includes causes of action and claims that are known or unknown, specifically mentioned or implied, or neither mentioned nor implied, which might exist or be claimed to exist at or prior to the date of this document or that accrue while you participate in the counseling sessions.

RESOLUTION OF CONFLICTS: On rare occasions, a conflict may develop between a counselor and a counselee. In order to make sure that any such conflicts will be resolved in a biblically faithful manner (see 1 Corinthians 6:1-8), we require all of our counselees to agree that any dispute that arises with a counselor or with any person or entity associated with the counselor (including Christian Family Chapel) and related in any way to his/her biblical counsel will be settled in the following manner: First the parties agree to participate in biblical mediation to be conducted by an individual (or individuals) agreed upon by the parties or , if no agreement is reached, by an elder at Christian Family Chapel, or, if one is not available, a Christian biblical mediator located in the metro Jacksonville, Florida area who is certified by Peacemaker Ministries and/or by the Association of Certified Biblical Counselors. The parties agree to participate and mediate in good faith. Second, if mediation is unsuccessful, the parties will submit their dispute to legally binding arbitration in accordance with the Rules of Procedure of the Institute of Christian Conciliation. Initially, the parties shall split the costs of the arbitration equally between the two sides. Notwithstanding the release you gave in the previous section, counselee waives all rights to special, consequential and punitive damages of any nature and waives all claims for negligence arising out of any act or omission of the counselor or anyone working with him/her. This agreement and the issues raised in counseling are not matters of public interest; they are private and relate to personal faith and Scripture. Judgment upon an arbitration award may be entered in any court of competent jurisdiction so long as the terms of this agreement were followed. Each party will be responsible for his/her own attorneys’ fees, although the prevailing party in any such arbitration shall recover his/her arbitration costs (not attorneys’ fees). The determination of “prevailing party” shall be made by the conciliator/arbitrator after taking the circumstances and claims into consideration. This entire agreement shall be binding upon the counselee and his/her family members, assigns and heirs.

SIGNATURE OR ACCEPTANCE: By signing this document, you are irrevocably waiving any right that you might have to a trial by jury or judge in a judicial proceeding. If any provision of this agreement shall be held invalid, illegal, or unenforceable, only that provision shall be stricken, and the remainder of the agreement shall be in no way affected. An executed facsimile copy or e-mail delivery of a “.pdf” format data file, shall be an acceptable form of acceptance of this Consent. Likewise, an electronic submission of a Personal Data Inventory (Request for Counseling) via Christian Family Chapel’s website or App shall be an acceptable form of acceptance.

When requesting counseling for a teenager, a consent to counsel must be signed by the teen and a custodial parent. If this is the case have the teen consent first, then an opportunity for parent consent will be available.

2026 | Personal Data Inventory