Instructions: Please complete the survey as accurately as possible, including any information that you feel could benefit the counseling process. All information contained in this survey is confidential except as prohibited by state / federal law regarding major criminal offenses and child, elderly, or disabled persons abuse.

The mission of Head to Heart Restoration Ministry is to provide emotional and spiritual wholeness to broken and wounded people through the power of Jesus Christ. Head to Heart Restoration Ministry is a 501(c)3 nonprofit pastoral counseling ministry.  Persons receiving counseling/ministry understand that:

Counseling is faith based Christian counseling.  Counselors are ordained ministers or “Domestic Missionaries” with a counseling focus.  In addition to talk/cognitive therapy, counseling techniques include prayer, the use of scripture, and biblical principles.

• Counselors are not licensed by the State of Texas as Licensed Professional Counselors.
• Clients have a right to confidentiality, although it is not an absolute right. Common reasons confidentiality may be violated include:
  • Client is suspected of physical or sexual abuse or neglect towards children, the elderly or the disabled.
  • When a client discloses their involvement in physical or sexual abuse or neglect towards children, the elderly or disabled.
  • When a client is in danger to self.
  • When a client is in danger or as threatened to harm others.
  • When a client appears gravely disabled and unable to make a rational decision as to his or her need for emergency treatment.
  • When a client appears in medical crisis and unable to grant permission for release of information.
  • When there is a court subpoena for client records or information.
  • Head to Heart Restoration Ministry counselors have a right to consult with each other regarding client issues, while maintaining confidentiality within the organization/ministry.

• Counselors will not testify in court or release counseling notes or documents on behalf of clients unless required by a court subpoena. This includes testifying on behalf of clients for divorce or child custody hearings.
• Counselors are not licensed attorneys and/or medical doctors. Information provided is strictly opinion and is not intended to be legal and/or medical counsel or clinical diagnoses.
• Clients are fully responsible for all decisions they make in regards to counseling recommendations and/or suggestions.
• The termination of the counselor/client relationship occurs when:
  • The client informs the counselor that they do not believe they need additional counseling
  • The client does not schedule additional sessions
  • The client does not call to reschedule or show up for a scheduled session
  • The counselor recommends that the client be referred to another counselor or professional
  • The client and counselor mutually determine that counseling services be discontinued
  • Non-payment of agreed upon fees
• Fees for counseling services are required at the time of the appointment. The standard fee is $85 per session. There is a $3 per transaction fee per credit card payments.
• If a reduced rate or financial assistance is being requested, a Reduced Rate, Sliding Scale and Benevolence Fund application is required. The number of sessions available for reduced rate clients may be limited.
• Client’s will be billed the full session rate for cancellations not made 24 hours in advance.
• Not showing up and not canceling in advance will result in full session payment.