Name

First Name

Last Name

This RELEASE and Waiver of LIABILITY is made and entered into on this date by and between Women Becoming Whole Counselors or Associate Counselors and name as stated above (counselee).

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As a precondition to any and all counseling/mentoring services to be provided by the counselor, the undersigned, in consideration of the services provided by the counselor, both parties acknowledging the adequacy of said consideration, does hereby remise and release from any and all injuries, losses, damages, liabilities, defenses, claims, actions, causes of action, suits, debts, promises, demands, or agreements, of whatever nature or kind, known or unknown, whether based in law or in equity, that either party hereto ever had or now has or that any one claiming through or under either party may have or claim to have, which was raised or asserted or could have been raised or asserted against the other party at any time prior to the execution of this agreement, including, but not limited to, any and all claims arising out of, by reason of, or in any way related to the subject matter of the mentoring relationship/services as a direct or indirect result of any involvement Mentee may have with the mentor or the mentors church or any other partnering/hosting church.

I Agree

Confidentiality is an important aspect of the spiritual friendship relationship, and we will carefully guard the information you entrust to us. All communications between you and our counselor will be held in strict confidence, unless you (or a parent in the case of a minor) give authorization to release this information. The exceptions to this would be: 1.) if a person expresses intent to harm himself/herself or someone else; 2.) if there is evidence or reasonable suspicion of abuse against a minor child, elder person, or dependent adult; 3.) if a subpoena or other court order is received directing the disclosure of information; 4.) if/when mentors consult with their supervision; or 5.) if a person persistently refuses to renounce a particular sin (habitual unrepentant rebellion against the Word of God) and it becomes necessary to seek the assistance of either terminating the mentoring or bring in others in the church or their family to encourage repentance, restoration, and reconciliation (Matthew 18:15-20). Please be assured that our mentors strongly prefer not to disclose personal information to others, and they will make every effort to help you find ways to resolve a problem as privately as possible.

I Agree

Natural Health Client Statement

I hereby attest to the following: That I am here, on this and any subsequent visit which includes Phone or email appointments, solely on my own behalf and not as an agent for any federal, provincial, municipal or professional agency on a mission of entrapment or investigation. I fully understand that Jaime Jacinto (or affiliated Women Becoming Whole Counselors) is/are not a medical doctor and I am not here for medical diagnostic or treatment procedures. The services provided by Jaime Jacinto at Women Becoming Whole (or affiliated Women Becoming Whole Counselors) is/are at all times restricted to education and guidance on the subject of natural health matters intended for general natural health well-being and do not involve the diagnosing, prognosticating, treatment, or prescribing of remedies for the treatment of any disease, or any licensed or controlled act which may constitute the practice of medicine in this state or province. This service is also holistic in nature and not one-on-one nutritional counseling as a State licensed nutritionist would perform. I am a Natural Health Educator and Counselor. This agreement is being signed voluntarily and not under any pressure of any kind.

I agree

The counselee further understands that it is the specific intent and purpose of this legal document to release and discharge any and all claims and causes of action of any kind or nature which are directed toward a mentor, mentee, Counselor, Pastor or Church. This includes causes which are known or unknown, specifically mentioned or implied, or not mentioned nor implied, which might exist or be claimed to exist at or prior to the date of this document. The undersigned recognizes the counselor is able to stop counseling at any time due to conflict, differences in religious opinion, or for any reason the counselor deems necessary as a religious organization. The undersigned waives all right to sue or file a charge against the counselor or Women Becoming Whole. The undersigned further specifically waives any claims or right to assert that any cause of action or claim or demand has been, through oversight or error, intentionally or unintentionally omitted from this release. The undersigned also understands that the mentor has been trained through Women Becoming Whole, but is not state licensed and not under the regulatory authority of any governmental agency. Also, when the term mentor/counseling or counselor is mentioned above it does not refer to psychiatric or psychological state licensed professional, psychiatric, legal or clinical medical advice provider. The advice given is based on how to think rationally and clearly from a Christian Biblical perspective. The nature and source of all information given comes from the Bible along with added non-traditional health and wellness resources, and therefore is sometimes referred to as Biblical Counseling, Discipleship Counseling or Whole Health Mentoring.

I Agree

I HAVE READ AND UNDERSTAND ALL OF THE ABOVE: Digital Signature

First Name

Last Name

Date

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