The information in this form is for the purpose of requesting counseling sessions. This information will be held confidential and the client named above gives consent for the church ministry member listed above to provide Genesis Counseling with appropriate information necessary to arrange for counseling services. The client also gives Genesis Counseling permission to contact him or her at the telephone number provided below to arrange for an appointment.

When a ministry referral is made by the church to Genesis Counseling Center, the ministry member making the referral is considered part of the counseling team and that information, as appropriate, may be shared between Genesis Counseling Center with this ministry member. The client understands this consent will expire one month after counseling service from Genesis Counseling Center ends. If, for any reason, the client wishes to withdraw this authorization for collaboration the client must provide written notification to Genesis.

The church is willing to assist in funding the counseling services as indicated below. If the client does not attend a scheduled appointment and does not cancel appropriately, the client is responsible for the missed appointment fee. Genesis Counseling Center will attempt to bill the client’s insurance, if appropriate. If insurance payment is authorized, Genesis Counseling Center will only bill the church for the client’s portion amount, which may vary depending on insurance.