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    I hereby give my permission and consent to James Harold Davis, Jr., Pastor to provide counseling treatment to

    Printed Name of Client

    Printed Name of Client

    I understand that I am fully responsible for any and all donations for any services which I have received. I understand that I will be charged for any appointment not canceled within 24 hours’ notice. I am aware that I may terminate my treatment at any time without consequence. I am also aware and consent to being audio/video taped for clinical supervision purposes.

    I certify, with my signature below, that I have read, had explained to me when necessary, fully understand, and agree with the contents of this Consent for Treatment.

    Signature of Client

    Date:

    Signature of Client

    Date:

    Signature of Legal Guardian: (If applicable)

    Date:

    I have received a copy of this document:

    Signature of Pastor:

    Date:

    INFORMED CONSENT TO AUDIO/VIDEO TAPE

    I will audio/video tape counseling sessions for the purpose of improving my clinical skills and to obtain additional clinical training. Confidentiality concerning such tapes is considered the same as the counseling sessions themselves. Following feedback from my clinical supervisor, the tapes will be erased.


    I,

    give permission to James Harold Davis, Jr., Pastor to:

    All counseling sessions unless otherwise expressed.

    Client

    Date:

    Client

    Date:

    Legal Guardian (if applicable)

    Date:

    Pastor

    Date:

    The decision to enter into a Pastoral Counseling relationship is a serious commitment that can be a life-changing experience. Research has shown that individuals who understand “Godly” counsel are more likely to achieve favorable results.  This document is designed to inform you of the Pastoral Counseling process, the various Holistic modalities that I use, the benefits and risks involved in Spiritual Counseling, confidentiality, our professional relationship and my background.  It will also document your understanding of and consent to treatment.

    Background and Training

    I have a Master’s of Science (MS) degree in Clinical Mental Health Counseling from Walden University in Minneapolis, MN.  I received a Board of Regents degree from Marshall University in 2010.  I am also an Ordained Elder/Pastor within the Church of God In Christ, Inc. (Charlotte, NC), and Director of Pastoral Care at God’s Tabernacle Church, Inc. Most of my counseling experience has been pastoral in nature since I have been in a pastoral role since 2005.  I began my clinical training in 2020 upon entering the counseling program at Walden University. The experience I have comes from working with individuals, couples, children and families.  Clients with whom I work generally seek counseling for difficulties associated with common life.  This includes depression, anxiety, grief, loss, adjustment difficulties, self-identity issues, life goals, relationship issues, substance abuse issues, marriage and pre-marital issues.

    Pastoral Counseling Services Offered

    With respect to my Biblical orientation and worldview for Pastoring, I believe that we are whole persons, with physical, psychological, social and spiritual aspects, so therefore I am committed to an integrated approach of Pastoral Counseling. These Biblical perspectives are based upon God’s principles.  I respect your religious/spiritual orientation and therefore whether we include discussion of the spiritual dimension of life in our time together will be entirely up to you.

    Guiding Principles and Practices

    My approach to Pastoral Counseling is Goal-oriented; Experiential; Multidimensional; Designed to enhance awareness and understanding: Collaborative: and means for accomplishing them; Continuous; Spiritually/Religiously sensitive; and Contemplative:

    Client Population

    I will agree to meet with a potential client regardless of age, color, culture, disability, ethnic group, race, religion, or economic status. I may decline a meeting with a client if I feel, in my professional opinion, that I cannot help them or if they would be better served with the services of another professional.  If a referral elsewhere is needed, I will provide information regarding services for the client’s consideration.

    Pastor’s Responsibility

    As a professional, I will uphold and abide by the standards of the Word of God. Our relationship is a professional one. Our contact will be limited to the sessions you arrange with me. You will be best served while I am seeing you for counseling if our relationship stays strictly professional and if our sessions concentrate exclusively on your concerns.  You may learn more about me as we work together, but it is important for you to remember that you are experiencing me as a Pastor.

    Client’s Responsibility

    The beginning sessions involve understanding your situation so that together we can develop specific, realistic goals, methods to accomplish them and the approximate length of time needed. It is important for you to be as open and honest with me as possible and work toward the goals we have agreed upon. The majority of the counseling session will consist of you talking about the issues you present and employing methods that can help make a positive difference in your life. This requires effort and active involvement on your part to understand and change your thoughts, feelings and behaviors. It will include work in and out of the counseling sessions and may include homework assignments, self-observation and practicing new behaviors. It is important for you to attend all of your scheduled appointments on time.

    Confidentiality

    I regard the information you share with me with great respect. All information that you share with me including notes and records as well as assessment results is confidential and will not be released to any outside person or agency without your written authorization and consent.

    The following are circumstances in which I cannot guarantee confidentiality, either legally or ethically:

    If there is abuse (potential or actual) of children, persons with disabilities, and/or senior citizens.  The law requires the                      Pastor to report it to the appropriate authorities.
    If disclosure is required to prevent clear and imminent danger to yourself and/or others.
    If mandated by a court of law.

    In order to improve my Pastoral skills and obtain additional training I may audio/video tape counseling sessions. Confidentiality concerning such tapes is considered the same as the counseling sessions themselves.

    Session and Fees

    I can assure you that my services will be provided in a professional manner and will be consistent with accepted ethical standards.  After we decide on the frequency of appointments (generally once a week) and the appointment time, I will reserve this time for you.  Sessions are usually 45 – 50 minutes long. It is possible to adjust the length of a session if necessary and should be agreed upon in advance.  The length of treatment varies depending on the client(s) and the nature of the problems.  Typically, treatment will last 8-12 sessions for relatively specific problems but may be longer or shorter depending upon the nature of treatment.

    The counseling fee structure are as follows: Clients may use their Zelle to submit their donation. Please understand that you, the client, are fully responsible for your donation for services, and the donations are due prior to each session(s). Again, donations are accepted in the form of cash, check, and your Zelle account.  Please note that if your check is returned for insufficient funds, you will be responsible for the bank charges incurred.  Cancellation of appointments must be made 24 hours prior to your appointment.  If the appointment is not canceled within this time period or if you do not show up for your appointment, you will be charged a $35 missed appointment fee. There is a one-time Intake form fee of $100, and you are asked to give a donation per session no less than $95, unless stipulated otherwise upon agreement with the client and Pastor.

    In Case of Emergency

    If you try to contact me by phone and I am not available, please leave a message on my voice mail.  I will return calls within 24 hours.  If you are unable to reach me in an emergency, contact 911 or go to the nearest hospital emergency room.

    Social Media and Electronic Communications

    Social Media is neither private nor confidential.  Therefore, I will not seek out or accept “friend” requests or “follow” any current or former client on any social media platform.  With this being said, I will not engage you in any public forums over the Internet, because to do so could blur the professional nature of our relationship and could compromise the privacy that I seek to guard.  Electronic communications (E-mail, texting (SMS), etc.) are not encrypted or secure and may not be received in a timely manner. The best method is to contact the office, or the phone number given.

    Complaint Procedure

    If you are dissatisfied with any aspect of our work, the most effective and productive way to deal with the situation and hopefully resolve it is to discuss it in our sessions together.  Please feel free to ask any questions or clarify any confusion you may have about our work.