Faith-based Counsel & Care Service Agreement

Thank you for choosing Beauty For Ashes Healing for your confidential care. I look forward to working with you as God moves you toward healing and successful changes in your life and relationships.

When we meet for a scheduled counsel & care session, here is what you can expect:

SCOPE OF SERVICE

Our scheduled counsel & care session will take place in-person or live online via Zoom. This will be agreed upon when your appointments are scheduled. You will receive an email or text with online meeting links if applicable. All counsel & care sessions will last 60 minutes. Confidentiality and trust will be held as paramount; everything you say will stay here. The only exception is if you threaten to harm yourself or others. Your emergency contact or proper authorities will be notified in such an emergency situation. Your counsel & care provider maintains a level of professional neutrality during the duration of our arrangement; client(s) agree not to have confidential records subpoenaed or deposed in any legal proceeding, per AACC's Ethics Codes 1-630-b and 1-630-c.

PAYMENT INFORMATION

You should receive an email invoice 24-48 hours before scheduled appointments; the link for payments is through Square. Sessions are $60/hour flate fee, with a 15% discount applied for 4 pre-paid sessions

(discount package total: $204). Please provide payment for counsel & care services prior to scheduled appointments. You will receive email confirmation of payment. You may print out your invoice for your

records. NOTE: Beauty For Ashes Healing does not accept medical insurance.

SCHEDULING AND CANCELLATION POLICY

All appointments will be made by completing the online booking registration for. Reminders are usually sent 24 hours before scheduled

appointments via email. If you need to cancel or reschedule an appointment, please do so 24 hours or more in advance. Noshows

will not be refunded, including for pre-paid discount packages.

COMMITMENT TO QUALITY COUNSEL & CARE

Samantha Wright has received certified training that is faith-based. However, she honors and respects everyone who is interested in receiving help, regardless of their religion, race, sex, or value

system. If you are comfortable, then I am comfortable. If you are not comfortable, I will gladly refer you to a care professional you are more comfortable with. Beauty For Ashes healing reserves the right to end any counsel & care relationship for any reason.

INDEMNIFICATION

Clients of Beauty For Ashes Healing understand that faith-based counsel & care is not a substitute for licensed medical or mental health care. Beauty For Ashes Healing does not diagnose or treat physical or mental illness. Clients of Beauty For Ashes Healing do not hold this business

responsible for the outcome of counsel & care sessions. All advice, assignments, and action plans are based solely on what each client reports in confidentiality. Results are dependent on the client's own

efforts.

First name

Last name

Phone

Address

Birthday

Month

Day

Year

Emergency Contact and Relationship: Ex: Becky Smith, 123-456-7890, mother

Occupation or season of life

Employer's Name, if applicable. NA if not applicable

Significant Other's Name, if applicable. NA if not applicable

For all child(ren): Name, age, education, marital status if applicable. Ex. Son, John, 23, electrician, engaged to high school sweetheart. NA if not applicable

Are there children from a previous marriage or relationship?

Yes

Spouse or ex-spouse's age and occupation, if applicable. NA if not applicable

Is spouse or partner willing to come for counsel & care:

Yes

Date of marriage and ages when married. Ex: 5/19/1998 I was 21, he was 22. NA if not applicable

Length of dating and engagement. NA if not applicable

Were you reared by anyone other than your biological parents? Briefly explain.

Describe your sibling situation. How many older brothers and sisters. How many younger. Include step-siblings if necessary.

Have you ever been separated?

Yes

Currently Separated

Brief information on previous relationships, if applicable. NA if not applicable

List important present or past illnesses

Do you receive regular medical care?

Yes

Have you used drugs for reasons other than prescribed medical purposes (illicit, prescription, or over the counter)?

Yes

Have you turned to alcohol, substances, or other addictive/avoidant behaviors such as food, screens, p*rn, gambling, shopping, or hoarding? Please describe if applicable. NA if not applicable

Have you been interested or involved with the following; NOTE: these activities and attractionscan result in unwanted thoughts or effects. Yoga or Eastern/New Age Practices Horror or paranormal movies/literature Reading/gaming as escapism Mysticism occult

Yes

Have you ever been in recovery for hurts, habits, hangups, or addictions?

Yes

Have you dealt with miscarriage, infant loss, or infertility? Briefly explain.

Have you had an abortion (women) or had a partner who had one (men)?

Yes

Have you suffered the loss of someone close to you? If yes, please describe.

Have you suffered loss from serious relationship, social, business, or other reversals? Please describe.

Church or denominational history and preference. Please describe.

Church attendance. Check one.

Rarely if ever

Occasionally throughout the year

Often and consistently

Have you been baptized?

Yes

Religious background and commitment of significant other, if applicable

Do you believe in God?*

Yes

Maybe

Do you pray?

Yes

How much do you read the Bible?

Never

Occasionally

Often

Daily

Have you ever received pastoral care or prayer ministry/healing?*

Yes

Have you ever had any licensed counseling or therapy before? Please describe if applicable.

What problem are you seeking help for? Briefly describe.

What have you tried so far?

As you see yourself: what kind of person are you? Describe yourself briefly.

What, if anything, do you fear?

Is there anything else you would like to share? Briefly describe below.

Faith-based Counsel & Care Expectations

Beauty For Ashes healing offers faith-based counsel & care to serve those who desire to understand their problems and relationships -- and receive guidance -- from a Christian viewpoint. Each client who schedules sessions will be received and respected with the utmost confidentiality. Working

together to accomplish God's will is the goal, so there are expectations for each client and the care provider that can help achieve this. Please review the following expectations and mark each one as read.

I can be relied upon to be on time for all calls and appointments. If I meet online, I can eliminate outside distractions.

I am willing to eliminate or modify any self-defeating behaviors that may limit my success, with the hope that

I will rely on God to achieve change.*

I understand that Mrs. Wright's training is faith-based; however, I also understand that all clients are welcome to receive services from Beauty For Ashes Healing regardless of their personal beliefs.

I agree to the pricing and payment upon registration and I agree to respectfully attend to all payment invoices.

Beauty For Ashes Healing reserves the right to end a counsel and care relationship for

any reason.

Your faith-based counsel & care provider agrees to the following:

I can be relied on to be on time for appointments; if we meet online, client comfort and confidentiality are my highest priorities.
All clients will be shown respect, and all boundaries that are clearly set will be upheld by client and provider.
I am not a licensed therapist or medical provider; I am willing to refer anyone who is uncomfortable, or whose needs are more than I can manage, to a qualified licensed therapist or other care provider.
My faith and value system are my moral foundation. I understand that others may have different faith, church and worship, or doctrinal positions. I will respect each client's beliefs and ask that they respect mine as we work together to reach the client's wellness and healing for God's glory.

Signature

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