Intake Form

Intake Form
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Name*

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Address*

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Which of the following best describes your interest in our time together? Please mark all that apply.*

Share/process experiencesLearn more about prayerGrow in self-identity and/or self-acceptanceDiscern God's willBecome more inner-directedGrow in inner freedomHeal wounds from the pastGrow in self-awarenessShare/process grief, anger, joy, hope, etc.Address particular, habitual strugglesSupervision (I'm a certified spiritual director)Supervision (I'm in training to be a spiritual director)Discern ministry/business decisionsOther
By digitally signing this document, you consent to meet with Tom Elliott of DeepWardly, LLC for the agreed upon fee of $75 per session (45-60 minutes), payable at the time of the session unless otherwise noted. Also, you agree to pay for missed sessions or sessions that are cancelled without providing at least a 72-hour notice.

By digitally signing this document, you testify that you understand that Tom Elliott does not offer counseling or therapy, and that everything you share during sessions are kept confidential unless state law mandates disclosure, including such things as suspected child abuse and neglect, self-neglect, exploitation of the elderly or other dependents, and threat to harm others or yourself.
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