Counseling Acknowledgment Form

I, (Please print) ____________________ acknowledge my intentions in receiving counseling and agree to align myself with the following statements.

(Please initial each of the following to indicate that you have read and understood this acknowledgment.)

______ I am choosing to receive counseling of my own free will in order to gain spiritual and emotional benefits specifically related to my personal life, including emotional healing, counseling, and care

______ I do not intend to manipulate, harm, or intentionally embarrass myself, my counselor, or any other participant we may encounter in this journey.

______ I agree not to publicly post any negative statements or comments regarding my counseling experience or my counselor on any social media platform.

______ I affirm that I am not deceptively participating as a reporter, student, investigator, or research agent for any form of media or institution.

______ I affirm that I am not bringing any recording device (e.g., audio or video) to counseling sessions.

______ I understand that any violation of this agreement is grounds for immediate termination of counseling services and may result in legal action against me or any associated organization.

I hereby affirm that the above statements and intentions are true. I understand that these terms remain in effect for the duration of my participation in any counselor/client relationship. I agree not to breach the confidentiality of our sessions at any time. I further pledge not to knowingly or maliciously breach the confidentiality of others who may be connected in any way to these sessions.

Signature:

Date:

Release from Liability

I, (print name) ____________________________, acknowledge that I have voluntarily sought out counseling and emotional healing. I understand that my participation in counseling and emotional healing is not a substitute for psychiatric treatment, psychotherapy, therapeutic counseling, or any other form of therapy or counseling that operates under the authority and licensure of the State of Oklahoma.

I am voluntarily participating in counseling and emotional healing with full awareness of these facts and accept full responsibility for my own mental health, psychological care, physical, and spiritual well-being. I further acknowledge that my participation in the counseling and emotional healing offered by the counselor does not create any special relationship of control or custody between myself and the counselor. I retain my full autonomy and free will at all times.

As consideration for being accepted by (counselor’s name) ____________________________ to voluntarily participate in counseling and emotional healing, I, on behalf of myself and my assigns, heirs, executors, guardians, and legal representatives, hereby release (counselor’s name) ____________________________ from any liability for injuries or damages I may suffer during my voluntary participation in counseling and emotional healing, including those resulting from any negligent act(s) or omissions by the counselor or other participants.

Furthermore, I agree that I will not make any claim against, sue, or seek to attach the property of (counselor’s name) ____________________________. I hereby waive any and all actions, claims, or demands that I now have or may have in the future for any injury or damages resulting from the negligence or actions of the counselor or any other participants in the counseling process.

I have read and fully understand the contents of this agreement. I acknowledge that this is a release from liability and a binding agreement between myself and (counselor’s name) ____________________________. I sign this agreement freely and voluntarily.

Signature:

Date:

Duty to Inform

According to state law, confidentiality and the privacy of communication are rights afforded to all individuals receiving counseling and emotional healing. However, the law and established court precedents recognize exceptions when an individual intends to engage in harmful, dangerous, or criminal actions—whether against another person or themselves, such as threats of suicide.

In such cases, it is the duty of the counselor, (counselor’s name) __________________________________, to notify the appropriate individuals or authorities. Those who may be informed include:

  • The person, or family of the person, who may be at risk of being harmed.

  • The family of the individual (disciple) who intends to harm themselves or someone else.

  • Associates or friends who may be involved or affected.

  • Law enforcement or other appropriate authorities.

Before any disclosure is made, (counselor’s name) _____________________________________ will make every reasonable effort to inform the individual receiving counseling of the intent to report. All possible steps will be taken to maintain confidentiality and to minimize any breach, only disclosing what is absolutely necessary to prevent harm.

By signing below, I, (print name) _____________________________________, acknowledge that I have read and understood the above information and understand that such disclosures may be made when deemed necessary for safety and legal compliance.

Signature: _____________________________________________________________ Date: ______________________

Parent or Legal Guardian (if under 18): _________________________________________________________

Witness: _______________________________________________________________ Date: ______________________

Counseling Fees & Financial Options

We believe healing should be accessible, not transactional. Our ministry operates with a heart for restoration, not profit. That’s why we offer counseling on a donation-based model—inviting you to give what you can, while receiving what you need.

Here are several ways you can engage with our fee structure:

  • Suggested Giving Based on Income

    This model helps ensure that everyone contributes fairly, based on what they’re able.

    • If your household income is between $5,000–$20,000, we suggest giving $25–$50 per session

    • If your income is $20,000–$35,000, consider $35–$55 per session

    • If your income is $35,000–$50,000, consider $40–$60 per session

    • If your income is $50,000–$75,000, consider $60–$65 per session

    • If your income is $75,000–$90,000, consider $75 per session

    • If your income is $90,000–$110,000, consider $90 per session

    • If your income is $110,000 or more, we suggest $110 or more per session

    You’re welcome to choose an amount within your range that feels honest, sustainable, and generous.

  • Monthly Healing Partnership

    Many clients choose to support our work monthly as a rhythm of giving:

    • $100/month helps cover partially sponsored sessions

    • $200/month helps cover your weekly session

    • $300/month helps fund your sessions + support others

    • $400/month or more sponsors a second client in need

    Monthly giving helps sustain the heart of this ministry long-term and is tax-deductible through My Brutiful. Life Ministries, a registered 501(c)(3) nonprofit.

  • Pay-It-Forward Giving

    Every session you attend is made possible by someone else’s generosity and now you get to do the same.

    If you’re able to contribute more than your session’s cost, we invite you to pay it forward. If you’re in a tight season, we get it. Please don’t hesitate to reach out and request a reduced rate we’ll do all we can.

  • Just Give What You Can

    If you’re overwhelmed by numbers and just want to be honest, simple, and real: you’re safe here.
    Let us know what you can give, and we’ll walk with you from there.