Sliding Fee Scale
Our fees are payable by cash, card, or check and are based on total household income. For a household with $50,000/annual income or greater, the fee is $110/hour, for $40,000/annual income, the fee is $90/hour, and for anything under $40,000, the fee is $75/hour. Sessions typically last 50-60 minutes unless requested otherwise.
COUNSELING CONSENT FORM
John Michael Helms Pastoral Counseling, LLC
By completing this consent form, you indicate that you understand and agree to the terms and conditions stated below.
- You agree that you are at least 18 years old. If you are under the age of 18, you will need a parent or legal guardian to complete this consent form. Please note: Sessions with minors are treated as confidential because counseling is most effective when trust is maintained. Parents may be allowed general (vague) updates, but no private session details. The counselor/coach will present you with information only when/if needed. You are required to remain in the waiting room during sessions with minors.
- You understand that while pastoral counseling is a unique form of psychotherapy provided by highly skilled and trained individuals who use spiritual resources as well as psychological understanding for healing and growth, we are not clinical psychologists, psychiatrists, medical doctors, lawyers, or licensed social workers. We cannot prescribe medicine or diagnose illness. All advice or coaching given to you is done so in good faith, in the spirit of emotional and spiritual well-being, in hopes that you will use good judgement and practical applications when appropriate, to the degree that you feel capable and comfortable. In addition, it may be suggested that you seek help with your pastor, a clinical counselor, or a medical doctor or psychiatrist, if that applies.
- If you wish to counsel by telephone, you agree that telephone counseling is not equally safe and effective for all individuals. Thus, we reserve the right to choose whether or not to work with you by telephone. If, during our work together, we discover that you are not a client that can benefit from telephone counseling, your counselor will discuss this with you and suggest that you seek face-to-face counseling help through other mental health professionals in your local area, such as a psychiatrist, social worker, or another pastoral counselor or life coach.
- You agree and understand that the effectiveness of counseling depends on the investment of time and energy you are personally willing to make. Generally speaking, the more you invest in it, the more you will get out of it. You may be asked to keep a journal, conduct a homework assignment, or read a book on a related subject. Please make every effort to participate fully. We are not responsible for your results or lack thereof, you are.
- You agree that neither your counselor/coach, in this case, Dr. Michael Helms, or any of his associates, is responsible for providing services to you in the event of an “urgent” crisis or emergency situation. This should NOT be an expectation of our services. While we will do our best to continue to provide peripheral kindness and concern, only as appropriate, if a crisis or emergency develops during our work together, you may need to go to the Emergency Room or call a medical or clinical mental health professional.
- We are not “on call” and cannot be expected to respond immediately in emergency situations. In an extreme emergency, you will need to call 911. You will typically not have access to your counselor/coach’s personal number or home address nor should you attempt to use these means to elicit a response outside of scheduled sessions.
- If you pursue contact with your counselor outside of the counseling relationship, you must use the PsychologyToday.com phone number: 678-326-4352 or email him through the PsychologyToday.com website.
- CONFIDENTIALITY: You understand and agree that as a counselor, we protect the confidentiality of the communications and contacts with all of our clients. We will only release information about our counseling relationship with your written permission except in the following situations:
a. If it is discovered, while we are working together, that a child, elderly person, or a disabled person is being abused or neglected, we are required by law and morality to notify appropriate protective services, agencies, or law enforcement officials.
b. If I am required to do so by a court order or legal subpoena or if you choose to pursue litigation against John Michael Helms Pastoral Counseling, LLC, Andrea Cook and Associates, Inc, or anyone associated with this organization. We will defend claims against us vigorously. You agree, by signing this form, to pay any and all expenses of our legal defense and any financial losses as a result of such including, but not limited to, injury to reputation or defamation by means of special damages. Furthermore, you specifically agree to mediation by an objective third party as a means of resolving conflict with your counselor John Michael Helms, LLC, and/or Andrea Cook and Associates, Inc. rather than litigation, at your expense.
c. If you tell me while we are working together that you are considering committing suicide, committing serious self-injurious behavior, or considering violence towards another person, or you demonstrate symptoms of delusions or hallucinations, or appear in a session to be under the influence of a substance that inhibits your ability to drive or care for yourself, I am required by law and/or morality to notify the appropriate authorities and/or family members. Be forewarned that self-harm or threats to others, neglect, abuse, including extremely harmful addictive behaviors/overdosing, and/or perceived psychoses are taken very seriously and additional help, such as medical or legal intervention, may be necessary and may not require your additional consent or prior knowledge to do so.
- The goal of my counseling is to help you. Therefore, if either of us feels, at any time, that working together is not helpful enough to you; either of us is free to terminate our relationship. There are no explicit or implicit commitments in our relationship.
- You agree to never record counseling sessions, through audio recorder, phone, video, or any other means, covertly or otherwise.
- You agree that this counseling relationship is best served if there is no legal basis for acquiring testimony for any purpose, including but not limited to, divorce, custody, and abuse cases. You agree that you will NOT subpoena your counselor for any purpose or “invite” your counselor to testify on your behalf, under any circumstances, as this is a violation of your privacy and the sanctity of the counseling relationship.
Fees are payable by cash, card, or check and are based on total household income. For a household with $50,000/annual income or greater, the fee is $110/hour, for $40,000/annual income, the fee is $90/hour, and for anything under $40,000, the fee is $75/hour. Sessions typically last 50-60 minutes unless requested otherwise.
Payment in full is expected at the time of each appointment. If you need a receipt, just let me know. Please notify me 24 hours in advance of a cancellation to give me time to book another client in that session time. If you fail to cancel 24 hours prior to your scheduled time, you will be charged the full rate for your missed session. Two no-shows will automatically terminate the counseling relationship.
Consent to pastoral counseling:
By signing this agreement, I acknowledge that I have read, understand, and agree to all of the terms and conditions contained in this form. I am voluntarily agreeing to receive pastoral counseling and/or life coaching for my own benefit and I understand I may stop this counseling service at any time for any reason.
Client Name (Printed) Date
Client Signature/Parent’s Signature if Minor Client
Phone number _________________________________________________________
Email address __________________________________________________________
Dr. John Michael Helms Pastoral Counseling, LLC Andrea Cook and Associates, Inc.