Intake Form.
PROFESSIONAL DISCLOSURE STATEMENT
My name is Angela Shutt. I completed the Ministry School for Prophetic Counsel through Living Waters in 2002. I received my Advanced Discipleship Training at Grace Life International in 2005. I am not a licensed counselor. I am the founder and principle operator of True Life Exchange. I come along side individuals to help them identify and live out the truth of their identity in Christ Jesus.
My name is Tim Shutt. I completed the Light University Professional Life Coaching and Recovery Coaching Program in 2016. I have thirty years of personal recovery. I received my Advanced Discipleship through True Life Exchange in 2016. I am not a licensed counselor. I come along side individuals to help them identify and live out the truth of their identity in Christ Jesus.
THE NATURE OF THE TRUE LIFE EXCHANGE CLIENT RELATIONSHIP
The client understands that the True Life Exchange relationship is not psychotherapy, psychological counseling, or any type of therapy; nor is it a substitute for these services. In the event the client feels the need for professional counseling or therapy, it is the responsibility of the client to seek a licensed professional who can provide these services. If the Truth Partner believes that such services will be valuable to the client, True Life Exchange will recommend them. True Life Exchange personnel may provide suggestions for change to the client, but the client is always seen as a person accountable for his/her own decisions. It is important to look at all of your life experiences from childhood to the present in order properly assess your current situation. At this point, I will help you to gain insight how these experiences are affecting your current situation, I will help you identify the “lies” that you believe and help you identify the truth. We will work on ways for you to make new choices that will positively affect your life. My main role is to be an encouragement and support to you during this process.
CONFIDENTIALITY
The information that you share with me during our sessions will be kept confidential. The privacy of our conversations and the records of our time together are a privilege of yours and are protected by state law and ethical standards. There are some circumstances in which I cannot guarantee confidentiality:
If the True Life Exchange personnel feels you are about to do harm to you, to someone else, or to property, they must, by law, take steps to protect the vulnerable party. Any suspected abuse of a minor, the elderly, or the handicapped must also be reported.
If the True Life Exchange personnel feels it would be in your best interest to consult with counseling colleagues, the reserve this right, while protecting your identity.
When a court orders a release of information
If the client is a minor, the True Life Exchange personnel will inform the parent or guardian of the True Life Exchange procedures. The True Life Exchange personnel may provide the parent or guardian with general feedback on the client, while maintaining privacy of the actual details of the sessions.
TERMINATION
Either party may end the True Life Exchange relationship by providing the other party with a one week written notice, which may be transmitted by email or fax.
LENGTH OF SESSIONS AND PAYMENT
The length of the sessions will be 50 minutes. Payment of $100.00 (cash, check or credit) is expected at the beginning of each session. Couples sessions with Anj Shutt are 50 minutes in length and $125.00. If a client chooses to go over the allotted time; if it is available, the cost will be at $1.50 per minute. If you need to cancel an appointment, please do so 24 hours in advance or as soon as possible. If I do not receive notice, you will be charged for the session. If your session is on Monday, you need to cancel by Friday of the previous week. Unfortunately, I cannot bill your insurance company.
CONSENT TO TRUE LIFE EXCHANGE RELATIONSHIP
While True Life Exchange utilizes electronic security, making every effort to keep your information confidential we are not responsible for a security breech. By filling out this form, I release True Life Exchange from the responsibility of keeping my electronic information secure.
During the course of our work together True Life Exchange personnel and the client may interact in social settings outside of True Life Exchange sessions. True Life Exchange personnel will respond to client’s initiation in these settings. If client has social media connections with True Life Exchange personnel before becoming a client of True Life Exchange, then all social media communications will be placed on hold until the client has completed their work with True Life Exchange. True Life Exchange will make every effort to respond within a reasonable amount of time but will not be available during non-business hours.
True Life Exchange is committed to keeping all information shared with True Life Exchange personnel confidential (except where legal obligations apply).
By filling out the form I, the undersigned, have read and understand the above information and am in agreement with the noted conditions for True Life Exchange. I give full consent to enter True Life Exchange as a client with Angela Shutt or Tim Shutt.