Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Preferred Method of Contact *

Phone

Email

OK to leave voicemails? *

Yes

No

How would you like to meet for Spiritual Direction? *

In-person

Virtually

Have you engaged in Spiritual Direction in the past? *

Yes

No

Confidentiality and Release of Information policies. *

Information shared in spiritual direction sessions is confidential and will not be discussed or released to anyone, except in cases where there is sufficient cause to believe that a life is in danger, or when you appear suicidal. In an attempt to gain perspectives and ideas as to how best to help you reach your goals, I may meet with other professional spiritual directors regarding supervision for our sessions, but will not identify specific information being disclosed. Spiritual directors are also required by law to report child abuse, child sexual abuse, elder abuse or intentions to harm self or others. In addition, if you have been a client of CCM in the past, your service history will be available to your Spiritual Director via our platform, Therapy Notes, but your Spiritual Director will not access your clinical files. If you would like your counselor and Spiritual Director to collaborate, you must give written consent. If you have any questions or reservations about the policy in regard to confidentiality, then the policy should be discussed before signing below. By signing below you are accepting the confidentiality policy, its limits and exceptions.

By checking this box I agree to the Confidentiality and Release of Information Policies outlined above.

Spiritual Direction Agreement *

Following are the guidelines for a spiritual direction relationship: 1. It is understood that the relationship pertains to and concerns the spiritual life of the directee. It does not directly concern itself with psychological counseling, psychotherapy, or medical practice of any kind. 2. Each session will last 60 minutes, beginning at the mutually agreed upon time. 3. Notification should be given within twenty-four (24) hours if an appointment cannot be kept by either party. Without such notification, directee will still be accountable for a payment of the usual fee ($65). I understand the above and agree to the terms set forth.

By checking this box I agree to the Spiritual Direction Agreement outlined above.