STATEMENT OF CONFIDENTIALITY

Please fill out the following form. You will receive a copy of your completed form via email.

If you need an offline copy of this form, please click here.

Informed Consent & Statement of Confidentiality

  • Welcome to Whole Hope Christian Counseling, LLC (EIN: 8 1 -4201353). In order that we start our relationship in a healthy way, we have put together this document to ensure that there are no misunderstandings about the various aspects of the counseling and wellness services.

    Background and Services We offer counseling and consultation services to individuals, couples, and families in the areas of mental health, spiritual health, physical and nutritional well-being, and relationships. Angel Beeson’s credentials include a Master of Biblical Counseling Degree, Health Coach Certification, and Holy Yoga Instructor Certification. John Beeson’s credentials include a Master of Divinity. Our interns are working toward their Masters of Biblical Counseling. As Biblical Counselors, we are not individually licensed therapists by the State of Arizona or any state which we reside. We offer religious counseling, not secular therapeutic psychological care. We offer biblically-based counseling, mediation, and conciliation services. The focus of our practice is adolescents and adults. We do not perform expert witness testimony in court. We do not prescribe or administer medication of any kind. We reserve the right to refer a client to another therapist or appropriate resource at any time if his or her needs in therapy are not a good match for our skills or experience. While Whole Hope Christian Counseling meets some clients at New Life Bible Fellowship Church, Whole Hope Christian Counseling is not affiliated in any way with New Life Bible Fellowship Church.

    Financial Payment is expected before or at the time the service is rendered unless other arrangements have been made. Because we are not licensed therapist, we do not work with insurance companies. Services are self-pay. For every week past due a charge of $10 will be incurred. By signing this document, you are agreeing to pay for the services rendered and any additional expenses that may be accrued. The fee for a counseling session with a counselor is $100/50 min. The fee for a couples counseling session with two counselors is $150/min. As Whole Hope grows, we reserve the right to inform clients of the price for our intern and associate counselors. The fees for intern and associate counselors range from $60-$80/50min. Reports required by physicians, employers, etc. will be assessed a $20.00 fee. A potential fee may be charged for telephone consultations in excess of 10 minutes. Checks returned by the bank will be charged an additional $15 fee. We reserve the right to change fees within 30 days’ notice. You have the right to be informed of all fees that you are required to pay and our refund and collection policies. Please discuss these with us if you have a concern.

    Insurance Whole Hope will not bill your insurance. We will be glad to provide you with an itemized receipt that you can submit to your insurance company in an attempt to receive reimbursement from them. Because we are not licensed therapist, it is unlikely you will recieve reimbursement.

    Availability of Services This practice does not have the capability to respond immediately to counseling emergencies. True emergencies should be directed to the local community emergency services (911) or to the local hotlines (Suicide hotline (800) 784-2433, Arizona Teen Crisis (623) 879-9600 EMPACT suicide, crisis hotline Maricopa County (866) 205-5229).

    Appointments Regular attendance at your scheduled appointments is one of the keys to a successful outcome in counseling. Appointments canceled at the last minute are detrimental to our practice and negatively impact other clients. Therefore, we ask that you notify us a minimum of one full business day (24 hours, Monday through Friday) prior to your appointment if you need to cancel. You will be billed the full fee for appointments you fail to cancel in accordance with this policy. Please note that these are personal financial obligations that you are responsible for, not the obligations of your insurance company.

  • Appointment availability varies with the client load at the time. High-demand appointments (evening hours and late afternoons) are likely to be sporadic in their availability. We reserve the right to limit our commitments of high-demand appointment times to any particular client to meet all our clients' needs.

    Privacy, Confidentiality, and Records Ordinarily, all communications and records created in the process of counseling are held with the utmost confidence between the counselor, counselee, and administrative personnel. However, there are numerous exceptions to confidentiality defined in the state and federal statutes. The most common of these exceptions are when there is a real or potential life or death emergency, when the court issues a subpoena, or when child or elder abuse or neglect is involved. We also participate in a process where selected cases are discussed with other professional colleagues to facilitate our continued professional growth and to get you the benefit of a variety of professional experts. While no identifying information is released in this peer consultation process, the dynamics of the problems and the people are discussed along with the treatment approaches and methods. If a client is under 18 years of age, please be aware that the law does provide your parents with the right to examine your treatment records. It is generally our policy to request an informal verbal agreement from parents to forfeit access to your records directly, and agree to be provided with general information on how your treatment is proceeding, unless we feel that you are in danger. There are also numerous other circumstances when information may be released, including when disclosure is required by the Arizona Board of Behavioral Health Examiners, when a lawsuit is filed against the counselor or Whole Hope, to comply with workers' compensation laws, to comply with the USA Patriot Act and to comply with other federal, state or local laws. The rules and laws regarding confidentiality, privacy, and records are complex. The HIPAA NOTICE OF PRIVACY PRACTICES details the considerations regarding confidentiality, privacy, and your records. Whole Hope's website contains information about a client's right to access his/her records and the details of the procedures to obtain them, should the client choose to do so. Periodically, the HIPAA NOTICE OF PRIVACY PRACTICES may be revised. Any changes to these privacy practices will be posted on the Whole Hope website. Clients will not receive an individual notification of the updates. It is imperative that you read and understand the limits of privacy and confidentiality before you start treatment. The process of counseling usually involves working through tough personal issues that can result in some emotional or spiritual pain for the client. Attempting to resolve issues that brought clients to therapy in the first place may result in changes that were not originally intended.
  • Purpose, Limitations, and Risks of Treatment Counseling, like most endeavors in the helping professions, is not an exact science. While the ultimate purpose of counseling is to reduce your distress through a process of personal change, there are no guarantees that the treatment provided will be effective or useful. Moreover, the process of counseling usually involves working through tough personal issues that can result in some emotional or psychological pain for the client. Attempting to resolve issues that brought you to therapy in the first place may result in changes that were not originally intended. Counseling may result in decisions about changing behaviors, employment, substance use, schooling, housing, relationships, or virtually any other aspect of your life. Sometimes a decision that is positive for one family member is viewed quite negatively by another family member. Change will sometimes be easy and swift, but more often it will be slow and even frustrating. There is no guarantee that counseling will yield positive or intended results. In the case of marriage and family counseling, interpersonal conflict can increase as we discuss family issues. As a christian counseling practice, we trust that God is at work in our lives. That promise, however, does not mean that change will be easy, or that trusting him will make our lives better.

    Treatment Process and Rights Your counseling will begin with one or more sessions devoted to an initial assessment so that we can get a good understanding of the issues, your background, and any other factors that may be relevant. You have the right to refuse any recommended counseling plan or to withdraw consent to treat and to be advised of the consequences of such refusal or withdrawal.

    Our Relationship The client/counselor/contractor relationship is unique in that it is primarily therapeutic. While biblical counseling is empathetic and relational, it is also differentiated from friendship. Because of this, it is inappropriate for a client and a counselor to become relationally enmeshed. The purpose of these boundaries is to ensure that client and counselor are clear in their roles in a counseling/counselor relationship and that confidentiality is maintained. If there is ever a time when a client believes that they have been treated unfairly or disrespectfully, we encourage them to talk with their counselor about it. There may be times where it is appropriate for client to bring such concerns to the President and/or board members. It is never our intention to emotionally damage clients. However, biblical counseling invites us to walk into trauma and pain for the sake of healing. In addition, sometimes misunderstandings can inadvertently result in hurt feelings. We want to address any issues that might get in the way of the counseling as soon as possible. This includes administrative or financial issues as well. The posture of the counselor’s heart is to see the client as a fellow image-bearer and saint who desperately longs to be loved and known. A biblical counselor appropriately expresses Christ’s love as a fellow brother/sister in Christ. As a counselor, we cannot speak into what we do not know. We work hard to ask questions in order to know well in order to speak in wisdom.

    Consent for Evaluation and Treatment Consent is hereby given for evaluation and treatment under the terms described in this consent document. It is agreed that either of us may discontinue the evaluation and treatment at any time and that you are free to accept or reject the treatment provided. In the case of a minor child, I hereby affirm that I am a custodial parent or legal guardian of the child and that I authorize services for the child under the terms of this agreement.

  • In the case of a minor child, please specify the following:

  • This field is for validation purposes and should be left unchanged.