Premarital Counseling Info Form
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Spouse #1 First & Last Name *
Spouse #2 First & Last Name
 *
Contact Email Address *
Contact Phone Number *
Have you ever had counseling before?  What was your experience like? *
How did you hear about CrossWinds Premarital Counseling? *
What's your current relationship status?  *
CONFIDENTIALITY Information disclosed in sessions is considered confidential and will not be revealed to anyone outside the center without your written permission, except when disclosure is permitted by law and deemed to be in the best interests of the client. The following are exceptions to confidentiality. 1. When there is a reasonable suspicion of child, elder or dependent adult abuse or neglect. 2. When the client presents a serious danger of violence to others or the property of others. 3. When the client presents a serious danger to harm him/herself. 4. Pursuant to a lawfully issued subpoena. Please initial below to indicate that you agree. *
PROCESS & COST - Each appointment will be 50-minutes and the cost is $85/session, payable in cash or via card through online form. This fee MUST be paid within 7 days of appointment, or future appointments will be given away. Please initial below to indicate that you agree.  
CANCELLATIONS - If you need to cancel an appointment, 24-hour-notice via text, phone, or email is REQUIRED. If you are a no-show or cancel less than 24-hours in advance, a $65 cancellation fee will be charged. Please initial below to indicate that you agree.
PASTORAL COUNSELING - CrossWinds Church pastoral counselors are not licensed clinicians. They have differing training and education that qualifies them for this role, and will happily provide that for you upon request. However, our belief is that pastoral counseling is a part of the net of care that we all need, and  information or conversations within the pastoral counseling context is not intended or implied to be a substitute for professional medical advice, diagnosis or treatment. Please initial below to indicate that you understand. *
LEGAL STUFF.   I knowingly and willingly waive and release any and all claims I may have against the church, the church representatives, church counselors and the church participants, and their respective successors, assigns, and/or affiliates (collectively, the “church parties”), related to any liability, loss, damages, injury, claims, costs, expenses, and/or attorneys’ fees of any kind that may be suffered by me, my family members, or any individual or individuals that I invite into church facilities or to participate in any part of any activities related to the church, which may arise, whether directly and/or indirectly, from participating in the counseling programs, and/or from any other activities contemplated by this agreement (whether negligent and/or otherwise on the part of the church, a church representative, a church participant and/or any third party). In no event will the church be liable to me or my family members, under, in connection with, and/or related to this agreement for any special, incidental, punitive, indirect, and/or consequential damages, whether based in breach of contract, statutory law, equity, warranty, tort, product liability, and/or otherwise, and whether church has been advised of the possibility of such damage. I understand that the church would not permit me to participate in the counseling programs, enter church facilities, and/or participate in any part of any activities related to church without agreeing to this waiver and release. I expressly agree and acknowledge that the foregoing waiver and release is intended to be as broad and inclusive as permitted by the laws of the state of California.     I agree to defend, indemnify, and hold harmless any church parties, from and/or against all claims, liabilities, losses, damages, costs, expenses, and/or attorneys’ fees of any kind arising from, whether directly and/or indirectly, (a) the counseling programs, (b) any action, inaction, and/or omission while on church premises, (c) my participation in any part of any activities related to church, (d) my non-compliance with applicable laws, and/or (e) my breach of this agreement and/or failure to follow the policies and procedures of the church. These indemnification provisions will survive the termination and/or expiration of this agreement. Please initial below to indicate that you agree. *
I agree that my electronic signature is the legally binding equivalent to my handwritten signature. Please initial below to indicate that you agree.  
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