Spiritual direction intake form

New clients: Please complete this form at least 24 hours before we meet. You’ll receive an email copy of your submissions.

Thank you!

Basic information about you

Name *

First

Last

Preferred pronouns

(For example: he/him/his, she/her/hers, they/their/theirs)

Email *

Cell phone number *

Alternate phone number

For example, home or work number

Okay to leave messages?

Cell
Alternate phone

Please check all that apply

Mailing Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Emergency contact information

Emergency contact's name *

First

Last

Contact number *

Relationship to you *

Background information about you

Please share as much or as little as you want.

Your age

Anything you’d like me to know about your background & identities (e.g., racial/cultural background, sexual orientation and/or gender identity, places you’ve lived, education, etc.)?

What would you like me to know about your spirituality?

How you spend your time (e.g., family, work, volunteer roles, hobbies, etc.)

Anything else you’d like me to know about you as a person?

Any questions or comments?