Informed Consent Form

1. Meetings: We will meet bimonthly for one hour and the cost is _______________ to be paid at meeting time. These monies are paid directly to __________________________________ either by cheque or by cash donation. An income tax receipt is available for donations over $10.00. No one in need of spiritual direction will be turned away because of one’s inability to pay. Your own hourly wage is acceptable.
2. Confidentiality: What is said in the meeting stays in the meeting room, except for the following: 1) Harm to self or others, 2) Child abuse or neglect, 3) Elder Abuse or neglect, 4) Domestic violence, 5) Unknowing sexual contact with HIV person.
3. Spiritual accompaniment is not psychotherapy: therefore I am not qualified to respond to crisis, and have made no provision to be contacted after hours. I am able to refer you to an agency or another individual should you need this.
4. I keep no records, except for my journal, for my own use, which is kept in a locked cabinet and confidential from others.
5. My training and experience: I completed a two-year program in spiritual direction from the Pacific Jubilee Program at Naramata Education Centre in 2012. I have a Masters of Education from the Ontario Institute for Studies in Education, U of T and a Masters of Theological Studies from St. Stephen’s College, U of A. I have completed over 1500 hours working in acute care, hospice, children’s hospital, rehabilitation, and residential care in the field of Spiritual Health (Chaplaincy). I am also trained in Healing Pathways.
6. I adhere to the Code of Ethics for Spiritual Directors http://www.sdiworld.org/sites/default/files/publications/Guidelines%20Revised%202014-proof1-2.pdf , and the CASC Code of Ethics http://www.spiritualcare.ca/code-of-ethics/ for those who are spiritual but not religious. I will make copies of these codes of ethics for your review if you are unable to access the sites.
7. My faith tradition is the United Church of Canada. I am open to all faith traditions and worldviews.  I believe that we are in constant dynamic transformation with the world around us.  Divine presence is appreciated as something in, through, and around us that is in continuous, creative change.  Life is fundamental oneness and energy operates open-endedly as a creative resonance of wonder, awe, probabilities and unpredictability.  I embrace uncertainty and ambiguity.  I believe that we have the capacity to create order through the process of acceptance, inclusion and transcendence.  Life can present us with challenges, yet out of these difficult times come creative possibilities never imagined. In spiritual accompaniment, space is held non-invasively, so that divine presence resonates and allows the possibility of emergence.
8. Beginning the Process: Initially we will have a conversation to determine if spiritual accompaniment is for you (Please see Initial Spiritual Accompaniment Meeting Questions). If you are committed to the process, we will contract for a period of three months to meet every two weeks or for 6 sessions. At the end of this period we will evaluate the process to determine if the spiritual accompaniment relationship is useful to you.  You are free to terminate the relationship at any time should you wish to do so.

Signature: _____________________________________________________        Print Name: _____________________________________________________

Date: _________________________________

Notes*

There is no fixed charge for Spiritual Direction; however, I suggest the equivalent of one hour’s wage for each hour of direction, or that you make a donation for each session according to your means.