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Please read clear to the bottom and fill out the form before your first session with Convergence Spiritual Care.
Once the release form has been filled out, a link will appear at the bottom to book your appointment.
As a Client of Convergence Spiritual Care (“CSC”) I acknowledge that consulting services provided by CSC will be in accordance with Christian biblical principles and precepts and will be conducted according to the guidelines and policies adopted by CSC, whether or not these policies are expressly stipulated or stated. Client understands and agrees that the Holy Spirit, through Scriptures and personal revelation, will be the sole and final standard by which CSC ministry and consulting services will adhere.
Client further acknowledges and agrees that ministerial and consulting services provided by CSC, are primarily spiritual in nature and are not intended as a substitute for medical treatment, therapy, legal services or law enforcement protection. Furthermore, Client understands and agrees that the consultants are, at all times, restricted to consultation and do not perform or otherwise participate in the advising, diagnosing, prognosticating, treatment of disease or any act which will constitute the practice of medicine in this state.
CSC's mission is to provide a safe place to share and find healing with confidentiality except when required by law. By law, there are certain situations in which information about Client or disclosed by the Client may be released with or without their permission. These situations include where children or elderly are at risk or physically or sexually abused, and in emergency situations where there may be danger to the client or others, as with homicide or suicide, confidentiality may be broken as proper authorities must be notified.
Telephone and video-conference providers, such as Zoom.com, do not guarantee confidentiality, though CSC will, to the extent of our ability. In the event a Client chooses to join a CSC group class or event, CSC is released from responsibility to keep client identification information confidential. We respect that your story is yours to tell.
Client acknowledges they have the opportunity to choose and freely enter into such consulting and ministerial services
with full rights and freedom to use ministerial services or consulting and to choose to not use them or discontinue consultations at any time. It is further understood and agreed that Client received no warranty, guarantee, or promise of any particular temporal or secular result either expressed or implied, from CSC, or its consultants, agents, representatives, employees, officers or board members.
For and in consideration of the receipt of information and consulting services from a consultant provided by Convergence Spiritual Care, Inc., the undersigned Client, being legally competent and fully authorized and empowered to do so, does hereby release, acquit and forever discharge CSC, its officers, employees, volunteers and all associated consultants from any and all actions, courses of action, claims, demands, injuries, damages, costs, loss of service, expenses and compensation, including legal fees, on account of any and all known and unknown personal injuries, mental anguish or agitation and/or damage claims to person or property resulting from or arising out of or related to consulting services and ministerial services provided by CSC and its agents, representatives and/or employees in any way affecting the undersigned parties.