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© 2023 Impact Family Inc. Powered by Global Presence Marketing

9050 Pines Blvd Suite #363 Pembroke Pines FL, 33024 | (877) 237-8540

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Step 1 of 3

Step 1: Basic Information

First Name*

Last Name*

Email*

Phone*

Birthdate*

Status*

Issue*

How did you learn about us?*

Name of Person Referred By

Step 3: Agreements

A. CHRISTIAN COUNSELING EXPECTATIONS

1. Christian/Biblical Counseling: Biblical counseling, also called Christian or pastoral counseling, centers on the Lord Jesus Christ. This type of counseling includes listening, teaching, encouraging, comforting, and guiding clients to a deeper relationship with Jesus. Our goal is to glorify God and help you reflect His grace and joy in your life. As Scripture says:

“He is the one we proclaim, admonishing and teaching everyone with all wisdom, so that we may present everyone fully mature in Christ” (Colossians 1:28-29, NIV).

“To equip his people for works of service, so that the body of Christ may be built up until we all reach unity in the faith and in the knowledge of the Son of God and become mature” (Ephesians 4:12-13, NIV).

2. Referrals to Professionals: If your issues require legal, medical, or other professional expertise, we encourage you to seek help from independent professionals. Our Christian counselors will work alongside these advisors to provide spiritual guidance from a biblical perspective.

3. Intent Listening: We encourage open communication so that your thoughts, worries, and concerns can be understood clearly, allowing for a tailored and compassionate counseling experience.

4. Assignments: Personalized assignments help you progress more quickly. They are designed to give insight and promote spiritual growth between sessions.

5. Accountability: We aim to help you grow in faith and glorify God. To achieve this, we encourage active participation in counseling sessions and any exercises assigned between sessions.

6. Length of Counseling: The number of sessions varies depending on the complexity of the issue and your engagement in the process. Some issues may be resolved quickly, while more complex problems, like marriage or addiction counseling, may require longer or more sessions.

B. CHRISTIAN COUNSELING AGREEMENT

1. Biblical Counseling: I (We) understand that the counseling provided will be based on biblical principles and is intended to glorify God and promote a Spirit-filled life.

2. Appointments and Cancellations: I (We) will honor our scheduled appointments or provide at least 72 hours' notice to cancel. If I cancel less than 72 hours before or do not show up, I will be charged for the session.

3. Confidentiality: Confidentiality is central to counseling, but if there is a risk of harm to myself or others, or if required by law, my counselor may share relevant information with appropriate authorities or individuals.

4. HIPAA Compliance & Session Notes: We use secured Company Google Workspace accounts with HIPAA compliance to share session notes. All data is stored securely with two-factor authentication. Before emailing any notes, we require your written consent, making you aware of any potential risks associated with email communications (e.g., breaches of privacy if not encrypted).

5. Cameras and Recordings: For quality assurance and security, we may record customer service and counseling/coaching sessions conducted via phone or webcam. Recordings are stored securely and can be deleted upon written request.

6. Legal Responsibility: I (We) will not hold Impact Family Inc. or its affiliated counselors legally liable for advice provided during counseling. I understand their role is to help me seek and understand God’s will, and I agree to resolve any disputes through Christian mediation services.

7. Legal Proceedings: I (We) agree not to subpoena any counselor or their notes for legal proceedings regarding matters discussed during counseling.

8. Follow Terms and Conditions: I (We) agree to adhere to all the terms and conditions.

C. CONTRIBUTION AMOUNT

We depend on the generous contributions of our counselees and partners. If you cannot meet the suggested amount, please discuss this with our team or apply for a scholarship. Suggested donations:

$85 per 50 minutes for new and existing client
$85–$150 per 2-8 hour workshops and group sessions

If you would like to support other individuals, couples, or families, please inquire about becoming a financial & prayer sponsor, or you can give one-time or recurring funds at www.impact.vision/donate. All contributions are tax-exempt.

D. PAYMENT DISPUTES

In the event of a payment dispute, I consent to Impact Family submitting redacted session notes to the involved merchant services or financial institutions to assist in resolving the dispute. This submission will include only the information necessary for verifying the details of the session, and intimate or sensitive details of the counseling sessions will be protected and excluded from the provided documentation. This measure is to support transparent and fair resolution while maintaining client confidentiality to the highest degree.

E. CHILDCARE POLICY

Unfortunately, we do not provide childcare. If you must bring a child, please ensure the issues discussed in counseling are appropriate for their presence.

F. CANCELLATION, RESCHEDULING & REFUNDS

1. Cancellation: If you cancel 72 hours before your appointment, you are entitled to a full refund. Cancellations can be made through your client portal. View tutorial.
2. No-Show Refund: If your counselor does not attend within 15 minutes of your scheduled time, you are entitled to a full refund.
3. Medical Emergencies: If a verified medical emergency prevents attendance, we will issue a coupon to reschedule your session.

You can manage all scheduling and refunds through your client portal at www.impact.vision.

CLIENT AGREEMENT

I have read and understood these terms. By signing below or contributing online, I agree to these conditions and consent to Christian counseling as described.

Client Name*

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Electronic Signature Agreement

By signing your name below, you are signing this consent form electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form.

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