Spritual Direction Intake Form

Spritual Direction Intake Form
Patient Name

First NameLast Name
Pronouns
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Preferred Method of Contact
Emergency Contact Information
Name

First NameLast Name
Phone Number
Format: (000) 000-0000.
Relationship
Spiritual & Religious Journey
Briefly describe the religious or spiritual tradition(s) of your childhood:
Are you currently active in a spiritual community, church or small group?
Current Spiritual Practices & Experiences
What spiritual practices currently feed your soul?
How would you describe your current image or experience of the Divine?
(e.g., God, Higher Power, Source, Universe, or a sense of deep mystery)
How would you describe the current season of your spiritual life?
(e.g., vibrant, dry, doubting, grieving, transitioning, waiting, feeling stuck)
Intentions for Spiritual Direction
What brings you to spiritual direction at this specific time in your life?
What do you hope to experience, discover, or cultivate through our sessions?
Are there any specific questions, decisions, or transitions you are currently discerning?
Life Context & Well-being
What major life events, stressors, or joys are you currently navigating?
(e.g., career change, relationship shifts, health issues, retirement)
Are you currently in therapy or counseling?
(Note: Spiritual direction is not psychotherapy. If you are in therapy, it can beautifully complement direction, but it does not replace mental health treatment.)
Logistics & Consent
Preferred meeting frequency:
Have you been convicted of drug related charges?
Preferred meeting format:
Statement of Understanding & Confidentiality
Everything shared in our sessions is kept strictly confidential, except in situations where there is a clear risk of imminent harm to yourself or others, or as required by law. Spiritual direction is a peer-to-peer relationship of spiritual companionship and is not a substitute for psychological counselling, financial planning, or legal advice.
I understand the nature of spiritual direction and agree to the session fee of $_____ per [hour/session].
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
*Your signature below indicates that the information you have provided above is truthful.
Signature
Should be Empty:

Spritual Direction Intake Form

Emergency Contact Information

Spiritual & Religious Journey

Current Spiritual Practices & Experiences

Intentions for Spiritual Direction

Life Context & Well-being

Logistics & Consent

Statement of Understanding & Confidentiality