Statement of Agreement Between Pastoral Counselor and Counselee

St. Matthews Pastoral Counseling Center

3515 Grandview Avenue Louisville, Kentucky 40207

502-896-8882

Statement of Agreement between Pastoral Counselor and Counselee

1. It is agreed that through professionally trained and experienced pastoral counselors, the St. Matthews Pastoral Counseling Center, Inc., will provide pastoral counseling to individuals and families on an individual and group basis in dealing with personal, marital, and family problems, including matters of religious concern.

2. It is agreed that all information about the counseling relationship will be used responsibly by both counselor and counselee. Information will not be shared by either the pastoral counselor or the counselee outside the St. Matthews Pastoral Counseling Center without consultation between counselor and counselee, which may sometimes include appropriate written permissions. It is agreed that information concerning the counseling relationship—with appropriate attention to confidentiality—may be used by the counselor in consultation with colleagues at the St. Matthews Pastoral Counseling Center, Inc. for the benefit of the counselee.

3. It is agreed that the fee for each counseling session will be $______. It is further understood that medical insurance payments cannot be accepted, and that this full amount is the responsibility of the counselee.

4. Payment is requested at the end of each counseling session. Checks need to be made out to the St. Matthews Pastoral Counseling Center. Arrangements related to payment of fees need to be negotiated with the counselor. Statements and receipts will be provided upon request.

5. It is agreed that appointments may be changed or cancelled with 24 hours' advance notice, except in cases of emergency, when less notice may be given. It is agreed that late cancellations and missed appointments may result in being charged for the session.

6. It is understood and agreed that the pastoral counselors of the St. Matthews Pastoral Counseling Center, Inc. are not physicians, psychologists, or attorneys, and do not offer medical, psychiatric, psychological, or legal consultations.

7. It is agreed that the pastoral counselor, in collaboration with the counselee, will aid in mobilizing the assistance of and in making referrals to other professional resource persons at times when this is indicated for the welfare of the counselee.

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Signature of Counselee Signature of Pastoral Counselor

Date: ______

In Case of Emergency, contact: ______

Address: ______

Telephone: ______Relationship: ______