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I understand that ________________________________ and those associated with them are not professional or licensed counselors, therapists, medical or psychological practitioners, unless otherwise indicated.

I understand the persons leading these sessions to be “encouragers” in the Christian faith, who are helping me assume my responsibilities in finding freedom in Christ.

I am also aware that my encourager may need to intervene if he or she suspects that a child (under the age of 18) or an elder (over the age of 65) is currently endangered by abuse or if I am a danger to others or myself.

I understand that I am not being advised to alter any prescription medication I am currently taking. This is a matter between my physician/therapist and myself.

I understand that I am free to leave at any time and am here voluntarily. I understand that I am under no financial obligation. I am also aware of my right to ask for clarification of any part of this statement or understanding.

If I am under age 18 (19 in Alabama) please check here ( ). I state that I am a mature minor (of college age and living away from parent / guardian) and have the capacity to consent to the terms of this release.

Name: _______________________________________ Date: __________________

Address: ______________________________________________________________

City: _____________________________ State: ______ Zip: ______________

Phone: _______________ Cell: _______________ Email: ____________________

Signed: _________________________________________