Counseling Request - Bayou Care Ministers

We provide individual, marital, and premarital counseling. Your response ensures we provide a timely and supportive experience.

Your name *

Email address *

Phone number *

Birthdate *

What type of Counseling are you seeking? *

Choose one: Individual, Marital, Premarital, or Other

How would you describe your current relationship with Jesus?

(This will not affect your ability to receive care. We simply want to understand where you’re starting from.)

What days and times are best for you to meet with a Bayou Care Minister? *

(Please list a few options that work well with your schedule. We’ll do our best to match your availability.)

By signing your name below you agree entirely with our Informed Consent as follows: *

1. Introduction

Welcome to The Bayou Church Care Ministries Program—a supportive, faith-based initiative. Please review these terms to understand the nature and scope of our services.

2. Purpose

We offer confidential care grounded in Biblical principles and informed by counseling theory to address personal, spiritual, and relational concerns. Care Ministers are not licensed professional counselors (LPCs) but are trained volunteers who follow ethical guidelines and comply with legal reporting responsibilities.

3. Confidentiality & Mandated Reporting

We value your privacy and aim to provide a safe space for sharing. Information shared will remain confidential except in cases where we are legally or ethically obligated to report. These include, but are not limited to:

Suspected child abuse or neglect
Suspected abuse or neglect of vulnerable adults
Credible threats of harm to self or others

These exceptions are required by law to protect the safety and well-being of everyone involved.

4. Voluntary Participation

Your participation is entirely voluntary. You may discontinue care at any time by notifying your Care Minister.

5. Role & Referrals

Our Care Ministers are not licensed counselors or mental health professionals. If your needs exceed the scope of this program, a referral to a licensed provider may be offered.

6. Risks & Benefits

While care conversations are intended to be supportive and encouraging, discussing personal issues may sometimes lead to emotional discomfort. We are committed to walking with you through any challenges that arise.

7. Sessions

Sessions typically last around 60 minutes and are held in private settings to protect confidentiality and foster trust.

8. Consultation

To provide the best support, Care Ministers may consult with the Care Director or other members of the Care Team. Information shared will be limited to what is necessary and will be handled with discretion.

9. Consent

By signing below, you confirm that you understand and agree to the terms above. The Bayou Church Care Ministries program is not a substitute for licensed professional mental health services. The Bayou Church assumes no liability for actions taken based on care conversations.

All digital submissions are stored securely and will only be accessed by authorized staff/Bayou Care Ministers for ministry purposes. We do not share your information with third parties.

Crisis or Emergency Disclaimer

Please note: Bayou Care Ministers are not available for crisis response or emergency situations. If you are in danger or need immediate help, call 911 or contact the National Suicide & Crisis Lifeline at 988.

Signature Here:

I agree to the terms of the Informed Consent and understand this serves as my electronic signature. *

Electronic Consent Acknowledgment

By typing your name (above) and selecting today’s date below, you confirm that you have read and understood the above Informed Consent. This action serves as your electronic signature, indicating your voluntary agreement to all terms and conditions outlined in this document.