Adult Online Info Form

​Online Adult Information Form and Privacy Disclosure
Please complete this form prior to your first appointment, whether an in-person or an online appointment.
Unless otherwise agreed, none of your information will be shared with anyone else.

I understand and have been advised that GRACE MATTERS based in Vancouver, Washington, and that as such; the counselors are well trained yet have not pursued licensure with the State of Washington or any other state they may be ministering in. I have also been advised and understand that, although the laws of confidentiality do not apply in these circumstances, my privacy and that of the counselor(s) will be respected and maintained in keeping with sound Biblical practices.

“Sound biblical practices” include:

  • Disclosure is required by law.
  • Information is revealed which indicates a genuine likelihood for harm.
  • Other counselors or leaders need to be consulted for advice on how best to address matters being discussed.

Sound biblical practices also include situations where either the counselor or I would be biblically compelled to discuss habitual or unrepentant sin with pastors, elders, or other leaders in the church, or to seek counsel in addressing a problem between the counselor and the counselee.

Whenever possible, the counselors at GRACE MATTERS try to work with the spiritual leaders of whichever church fellowship a counselee is a part of. If there is a biblically-warranted reason for NOT doing so, I will disclose that to my counselor at our first session or as soon as is feasible.

Since we are unable to accept insurance we ask for a donation of $55.00 per session. If more can be afforded that helps bless others.  If it is not affordable, any donation is welcome and considered enough. All donations are tax-deductible as Grace Matters is a 501c3 non-profit. Our EIN is 81-22404


By typing my full name here, I certify that I have read, understand, agree with, and consent this Privacy Disclosure Statement.