"Now that you know these things, God will bless you for doing them."  ~ John 13:17
  • Christian Coaching Services Agreement Consent Form and Intake

    with Jane Perkins
    Christian Coaching Services Agreement Consent Form and Intake
  • Birth Date*
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Current Life Season Which areas of life would you most like guidance or growth in?(Select all that apply)
  • Christian Coaching Services Agreement and Consent


    This document outlines the terms and conditions for participating in Christian Coaching services with Jane Perkins. Please read this agreement carefully before beginning coaching services.

    Christian coaching is a collaborative, faith-based mentoring process designed to support personal growth, spiritual development, and application of biblical principles to life challenges. This agreement ensures that clients understand the nature, scope, and limitations of coaching services.

    Participation in coaching services indicates that you have read, understood, and agreed to the terms outlined below.

  • NATURE OF CHRISTIAN COACHING SERVICES


    Christian coaching is designed to help individuals grow in spiritual maturity, develop greater clarity regarding life decisions, and apply biblical principles to personal challenges.

    Coaching may include:

    • exploring personal goals and life direction
    • identifying thought patterns and behavioral habits
    • developing spiritually grounded decision-making
    • applying biblical wisdom to everyday life situations
    • strengthening identity in Christ
    • learning tools for renewing the mind and responding to life challenges

    Coaching is educational, reflective, and goal-oriented.

    Coaching does not involve diagnosis, treatment, or prevention of mental health disorders.

  • DISTINCTION BETWEEN COACHING AND COUNSELING


    Jane Perkins is a licensed professional counselor in Illinois and Missouri. However, when providing Christian coaching services, she is not acting as a licensed mental health provider.

    Coaching services:

    • are not psychotherapy or mental health treatment
    • do not involve the diagnosis of psychological disorders
    • do not constitute a therapeutic relationship
    • are not medical or psychiatric services

    Clients who require mental health treatment may be referred to a licensed therapist or other appropriate professional.

    Participation in coaching services does not establish a therapist-client relationship.

  • CRISIS AND EMERGENCY SERVICES

    Christian coaching services are not appropriate for individuals experiencing a mental health crisis, suicidal thoughts, or urgent psychological distress.

    If you are experiencing a crisis, you agree to contact:

    • 911
    • your local emergency room
    • the Suicide and Crisis Lifeline (988)
    • a licensed mental health professional

    The coach cannot provide crisis intervention services through coaching.

  • CLIENT RESPONSIBILITY

    Coaching is a collaborative process. Clients are responsible for their own choices, actions, and results.

    Clients agree to:

    • attend sessions on time
    • participate actively and honestly
    • complete suggested reflection exercises or assignments
    • take responsibility for applying insights discussed during coaching

    Coaching is most effective when clients engage consistently in the process.

  • COACH RESPONSIBILITY


    The coach will:

    • provide a respectful and supportive environment
    • offer biblical insight and guidance
    • provide structured reflection tools and exercises
    • help identify patterns, goals, and possible next steps

    The coach will not provide mental health treatment or medical advice.

  • CHRISTIAN FAITH-BASED APPROACH

    Christian coaching services provided by Jane Perkins are grounded in biblical principles and Christian worldview perspectives.

    Scripture may be used during coaching sessions to explore spiritual themes such as:

    • identity in Christ
    • renewing the mind
    • faith and trust in God
    • spiritual growth and discipleship

    Participation in coaching assumes a willingness to explore biblical truth as part of the growth process.

  • CRISIS AND EMERGENCY SERVICES

    Christian coaching services are not appropriate for individuals experiencing a mental health crisis, suicidal thoughts, or urgent psychological distress.

    If you are experiencing a crisis, you agree to contact:

    • 911
    • your local emergency room
    • the Suicide and Crisis Lifeline (988)
    • a licensed mental health professional

    The coach cannot provide crisis intervention services through coaching.

  • NO GUARANTEE OF RESULTS

    While many individuals experience personal and spiritual growth through coaching, outcomes cannot be guaranteed.

    Personal results depend on many factors, including commitment, personal circumstances, and willingness to implement insights gained through coaching.

  • SESSION STRUCTURE

    Coaching sessions typically last 45 to 60 minutes.

    Sessions are conducted primarily through secure video conferencing unless otherwise arranged.

    The number of sessions varies depending on the client's goals and desired level of support.

  • TELEHEALTH COACHING

    Online coaching requires:

    • reliable internet access
    • a device with a camera and a microphone
    • a private location where conversations cannot be overheard

    Technology disruptions may occur. If connection problems arise, the session may be continued by phone or rescheduled.

  • CONFIDENTIALITY

    The coach respects the privacy of all clients and will not share personal information without permission except when required by law.

    However, because coaching is not psychotherapy, the legal protections of therapist-client privilege may not apply.

    Confidentiality may be limited if:

    • There is a risk of serious harm to yourself or others
    • Abuse or neglect of a minor or vulnerable person is disclosed
    • Records are required by court order

  • RECORD KEEPING

    Basic records may be kept for administrative purposes, including scheduling, billing, and session notes.

    Coaching records are maintained securely.

  • COMMUNICATION OUTSIDE SESSIONS

    Communication between sessions may occur via:

    • email
    • text message

    These forms of communication are intended primarily for scheduling or brief updates.

    Email and text are not secure methods of communication and should not be used to share sensitive personal information.

    Social media messaging will not be used for coaching communication.


     

  • FEES AND PAYMENT

    Christian coaching services are self-pay only.

    Insurance does not cover coaching services.

    Payment is due at the time of the session unless other arrangements have been made in advance.

    Clients may be required to keep a valid credit or debit card on file.

  • CANCELLATION POLICY

    Clients are asked to provide at least 24 hours' notice when canceling or rescheduling a session.

    Late cancellations or missed appointments may be charged the full session fee.

  • TERMINATION OF COACHING SERVICES

    Either the client or coach may terminate the coaching relationship at any time.

    If coaching services appear to fall outside the appropriate scope of coaching, the coach may recommend consulting a licensed mental health professional or another appropriate provider.

  • LIMITATION OF LIABILITY

    Clients understand that coaching services are designed for educational and spiritual growth purposes and that the coach cannot guarantee specific outcomes.

    Clients accept full responsibility for their decisions, actions, and results resulting from participation in coaching services.

  • ACKNOWLEDGMENT AND CONSENT

    By signing below, you acknowledge that:

    • You have read and understand this agreement
    • You understand the difference between coaching and psychotherapy
    • You voluntarily agree to participate in Christian coaching services
    • You understand that coaching is not mental health treatment

  • Acknowledgement

    I have reviewed this Professional Counseling Informed Consent Agreement. 

    I accept this agreement and consent to counseling.

  • Date Signed*
     - -
  • Should be Empty: