I understand this Agreement is a legally binding document controlling the terms and conditions of my participation in Warroad Community Church (WCC) pastoral care counseling ministry. I understand that WCC pastoral counseling ministry is non-psychotherapeutic, non-licensed, non-professional Christian counseling based on the Christian Bible and WCC Statement of Faith, offered by fellow brothers and sisters in Christ (“Pastoral Care”). My participation in the Pastoral Care is entirely voluntary, and I understand it is not a substitute for psychiatric, psychological, or other professional therapeutic services. I accept complete responsibility for my own psychological, emotional, and spiritual well-being, and I agree that I am solely responsible to ascertain my need for professional services and to obtain such services as needed. To the extent any WCC pastor, staff, elder, leader, intern or volunteer holds a license or certificate in a professional field, including without limitation, psychology, psychiatry, counseling, medicine, or law, I understand they are not acting in their professional capacity while participating in this Pastoral Care, and I will not attempt to hold them to any standards required by their licensure or certification. I understand that WCC makes no guarantee that participation in Pastoral Care will “fix” me or free me of unwanted symptoms, and I understand that all EXPRESS AND IMPLIED WARRANTIES ARE SPECIFICALLY DENIED. 

WCC values privacy and will endeavor to carefully guard my confidential information. I understand, however, that there are circumstances such as those listed below which may necessitate WCC sharing my confidential information: 

1. To consult with colleagues and supervisors, who will also endeavor to keep my private information confidential, to collaborate on how to best serve me, or for supervision and training of those providing Pastoral Care services; 
2. To prevent me from breaking the law, or harming myself or another person; 
3. To protect me from harm by another; 
4. To comply with a legal duty to report or other legal order; or 
5. To seek legal or other professional advice. 

For participants who are minors, WCC will also report suspected abuse and neglect to the proper authorities. WCC may also share confidential information with authorities and the minors’ parents or guardians if, during the minor’s participation in the Pastoral Care, the minor breaks the law, has sexual contact with another, or engages in any other activity that WCC believes, in its sole discretion, is harmful to the minor’s well-being. Minors will participate in small groups and/or accountability groups which are exclusively for minors and will be closely supervised. 

I understand that WCC Pastoral Care offers hope for those struggling with sexual and relational brokenness; including those struggling with sexual attraction to minors. WCC will take appropriate measures to protect the safety of all participants. 

To cover basic costs of its Pastoral Care program, WCC suggests a donation for each approximately 50-minute individualized counseling session. Preference is given to WCC church members and not all applicants to WCC Pastoral Care program can be accepted.  Those outside of WCC need referral to be considered.

In additional consideration for my, or my minor child’s, participation in the Pastoral Care, I agree, on behalf of myself and my minor child if he or she is participating in the Pastoral Care, and my and my child’s heirs, executors, guardians and other legal representatives, to release WCC, including its pastors, elders, officers, directors, employees, volunteers and other agents and those of any successor or affiliate of WCC, from all liability for injuries, damages or losses arising out of my or my child’s participation in the Pastoral Care, and I agree to hold the same harmless from any claim of liability asserted against any of them by me or on my behalf, or by my minor child or on his or her behalf.* 

By signing this Agreement, I affirm that I have thoroughly read and understood it, and unreservedly accept its terms. This Agreement will remain in effect as long as I or my minor child participates in the Pastoral Care, and the waiver and release of liability terms shall survive the termination of this Agreement. 

By providing information below you are giving your electronic signature to this agreement.

*Parent/Guardian signatures are only required if participant is under 18 years of age, in which case both parents/guardians’ signatures are required.