Counseling Session with Relief Corner, and its Employees, Volunteers, and Practitioners
Please read carefully and sign before participating in
any counseling services.
1. Purpose of Counseling Session:
I understand that I am participating in a free counseling
session provided by Relief Corner, which is a not-for-profit entity. The
counseling services are being offered by trained practitioners (who may be
interns or volunteers) for general/holistic psychological and spiritual health
support. These services are not intended to replace formal medical or
psychological treatment or a relationship with a licensed healthcare provider.
2. No Guarantee of Results:
I acknowledge that the counseling session is a voluntary
process and Relief Corner, and its practitioners do not guarantee any specific
outcomes. Counseling may assist with coping, emotional support, and guidance,
but I understand that individual results may vary.
3. Confidentiality:
I understand that the information shared during the
counseling session will be kept confidential according to the ethical standards
of the organization, unless disclosure is required by law (e.g., in cases of
suspected abuse, threats of harm, or other legally mandated circumstances).
4. Understanding of Services Provided:
I understand that the counseling session is intended to
provide general mental health support and is not intended to diagnose, treat,
or manage any psychological disorder or condition. If I require specific
medical or psychiatric care, I will voluntarily need to seek professional
psychiatric or psychological treatment at the nearest inpatient or outpatient
facility including emergency rooms, and call 911 for immediate assistance. In
some cases, I may be referred by a volunteer or practitioner to a licensed
healthcare provider in your state.
5. Voluntary Participation:
My participation in this counseling session is entirely
voluntary, and I can discontinue participation at any time without any penalty
or adverse consequences.
6. Release of Liability:
By signing this waiver, I release and hold harmless Relief
Corner, its employees, volunteers, and practitioners from all claims,
liabilities, or causes of action arising from my participation in the
counseling session.
7. Acknowledgment of Risks:
I acknowledge that although counseling services are
generally safe, I am aware of the inherent risks involved in discussing
personal matters that may elicit emotional responses or discomfort. I take full
responsibility for my emotional well-being and understand that it is my choice
to participate in the session.
8. Consent to Counseling:
I consent to participate in the counseling session and
understand that I may seek clarification or ask questions before or during the
session regarding the process.
9. No Financial Obligation:
I understand that the counseling session is offered free of
charge as part of Relief Corner's mission, and there is no financial obligation
or expectation for me to pay for these services.
By signing below, I acknowledge that I have read and
fully understand the contents of this Waiver and Release of Liability. I
consent to participate in the counseling session with Relief Corner and release
all liability as stated above.
Patient Name: __________________________________
Signature: ______________________________________
Date: __________________________________________
Emergency Contact Name ________________
Emergency Contact Phone ________________
For Office Use Only:
Counselor Name: __________________________________
Date of Session: ___________________________________
Session Notes: ___________________________________