Spiritual Direction Intake Form

First Name

Last Name

Birthday

Country

Time Zone

May we email you at the above address?

yes no

Phone Number

May we text you at the above phone?

yes no

How often would you like to meet?

Why are you seeking Spiritual Direction?

Is there anything else you'd like to share?

I have read and agree to the general polices below

yes no

General Policies

Currently all spiritual direction is with Rev. Brian Smith and typically sessions last 50 minutes.

Confidentiality is strictly maintained. Limits to confidentiality are in cases of potential danger to self or others or suspected, known abuse/neglect. Notes are not kept when sessions are completed. If the recipient is a minor there are rules about disclosure to parents/ legal guardians and boundaries will be clarified before ministry begins. A safe environment is important for effective growth.

Payments are due upon completion of each session and are preferred online, payment info will be sent to you in an email after each session. Accounts must be kept current in order to continue ministry with Wholeheartify LLC. Our base rate is $2 per minute.

Insurance: As a spiritual ministry we are not covered by medical insurance.

Cancellations/No Shows: If you must cancel your appointment, please communicate at least 24 hours in advance of your scheduled time. The second time you cancel with less than 24 hours notice, you will need to pay a non-refundable deposit before scheduling time. If we have to cancel within 24 hours, we’ll discount your next appointment $30.

Emergencies: If you feel that you need immediate help and/or are experiencing a medical emergency contact your nearest emergency room or family physician. If the emergency is psychological, ask for the psychologist or psychiatrist on call. If you are experiencing a life-threatening emergency call 911 or go to the nearest hospital emergency room.