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Counseling Agreement

Video Appointment

Phone Appointment

1-Christian/Biblical Based. I understand this is a faith-based (religious), Christian counseling service, not psychotherapy. Our Counselors are Licensed Christian Clergy and/or clinically trained professionals, and as such, will NOT counsel outside of scriptural biblical principles or doctrine. We, ALCC, have the right to refuse service if counseling requests are deemed outside of biblical morality. Some clear differences that we will not counsel in support of are divorce as a successful marital outcome, euthanasia (assisted suicide), immoral sexual misconduct (premarital/extramarital), abortion as acceptable solution, affirm non-heterosexual monogamous practices. In the unlikely event of subpoena, “the counselor” has the right to exercise his/her right to fully invoke the clergy/client confidentiality privilege for the sole purpose of protecting his position as clergy and the sacred trust of those he/she counsels. A copy of the American Association of Christian Counselors (AACC) Code of Ethics which we adhere to can be found here: http://aacc.net/files/AACC%20Code%20of%20Ethics%20-%20Master%20Document.pdf

 

2-No Guarantees. I understand no guarantees of any kind have been represented to me by “the counselor”, as to my personal experiences, or the possible results of this counseling. This is a collaborative relationship and I agree to put into practice those things that I learn in counseling.  

 

3-No Weapons. This building is a firearm and weapon-free zone. NO WEAPONS OF ANY KIND ARE ALLOWED.

 

4-Counselor and Qualifications. Terrell Pugh is an Ordained Minister of the Gospel and Licensed Pastor, licensed by House of David Ministries, Inc. 6782 N. Orange Blossom Trail Suite D11, Orlando, FL 32810, Telephone number 407-814-3890; email address: houseofdavidministries@riversofrevival.com – Advanced Certification, licensed by American Association of Christian Therapists (AACT), license # TP719655, Telephone number 601-833-4559. Taneisha Pugh holds a Master’s in Psychology from Walden University. Terrell Pugh also holds a Master’s in Marriage Couple and Family counseling from Walden University. ALCC’s counselors are not secular psychologists or psychiatrists who practice psychotherapy. Terrell Pugh and ALCC counselors are licensed as clergy/pastor and are subject to state clergy exemption laws as well as other exemptions to the requirement of state licensure for counseling (Georgia Code O.C.G.A. 43-10A-7).

 

5-Confidentiality & Limitations. ALCC operates under the clergy/client confidentiality privilege which means that communication between the counselee/client and minister of counseling is confidential. However, there are some exceptions when the counselor without the consent of the counselee/client may break confidentiality. I understand any threats of imminent harm to self, or others, including but not limited to, child molestation/abuse, and/or elder molestation/abuse, must be reported to the proper authorities without consent.

 

6-No Refunds & Payments. I understand there are no refunds for missed appointments. Appointment slots are not transferable. Once appointment time is missed there is no way to redeem lost time. I agree and understand payment for professional services is required at time of visit, before treatment, and that this office will not bill in lieu of payment. I will pay any legal fees, collection fees, and bank fees related to nonpayment of my bill, including worthless check charges, chargebacks and expenses resulting from bad payments. I accept full responsibility for charges for myself, my dependent children, or any of my responsible parties.  

 

7-Release of Liability. I release all liability, in any form, that may be charged against “the counselor”, by myself, or my estate, for actions concerning this counseling. The counselors and any related entities, Arise and Live Christian Counseling, Inc., shall not be liable for any damages or injury arising out of counseling. We, ALCC disclaims any and all liability for direct, indirect, incidental, consequential, punitive, and special or other damages, lost opportunities, lost profit or any other loss or damages of any kind.  I hereby take action for myself, my executors, administrators, heirs, next of kin, successors, and assigns as follows: I WAIVE, RELEASE, AND DISCHARGE from any and all liability, including but not limited to, liability arising from the negligence or fault of the entities or persons released, for my death, disability, personal injury, property damage, property theft, or actions of any kind which may hereafter occur to me including my traveling to and from counseling with ALCC, THE FOLLOWING ENTITIES OR PERSONS: ALCC and/or their directors, officers, employees, volunteers, representatives, and agents, and the activity holders, sponsors, and volunteers; (B) INDEMNIFY, HOLD HARMLESS, AND PROMISE NOT TO SUE the entities or persons mentioned in this paragraph from any and all liabilities or claims made as a result of participation in activities with ALCC, whether caused by the negligence of release or otherwise.

 

8-Terminating Counseling. Counseling is normally terminated by mutual consent between the counselee/client and counselor because they have reached the set goals. This can occur in either verbal or written form. However, both the counselee/client and counselor have the right to terminate counseling at any time. If you the counselee/client miss scheduled appointments, fail to schedule an appointment for follow-up sessions or do not reply to ALCC attempts to contact you, this will be understood that you have chosen to terminate counseling.

 

9-Emergency and Crisis Contact Numbers (Call 911 if an Emergency):

 

Suicide & Depression hotline

1-800-273-8255

Alcoholics Anonymous (AA)

aa.org

24/7 Hotline: 404-525-3178

Alcohol Rehab Guide

alcoholrehabguide.org

844-500-2558

Cocaine Anonymous

ca.org

1-800-347-8998

Gambler’s Anonymous

gamblersanonymous.org

1-877-664-2469

Sexual Assault Hotline

1-800-656-HOPE (4673)

Narcotics Anonymous

na.org

1-888-947-7262

Domestic/Family Abuse

1-800-621-HOPE (4673)

1-800-810-7444 (TDD)

National Domestic Violence

1−800−787−3224

Child Abuse Prevention

1-800-342-7472

24/7 Prayer Line/Text

1-866-987-7729

Child Abuse Hotline

1-800-342-3720

Elderly Crime/Abuse

1-866-552-4464

1-800-222-8000

The Covenant House

Nineline.org

1-800-999-9999

1-800-999-9915 TTY

National Runaway Hotline

1800runaway.org

1-800-RUNAWAY

Mental & Substance Disorder

1-800-662-4357