Individual Supportive Meetings Procedures & Disclosure Form

Supportive Meetings Procedures and Disclosure Statement

Your Name

Your Email

DOB

Your Address

Cell Phone

Home Phone

Occupation

Marital Status

EMERGENCY CONTACT
Emergency Contact Name

Relationship

Phone Number

Date of First Appointment (if scheduled)

PROCEDURES
Supportive meetings are 50 minutes long. Please offer 24 hours advance notice if you need to reschedule.

DISCLOSURE STATEMENT
I am legally ordained as a minister and transpersonal counselor by the Association for the Integration of the Whole Person. I will not be practicing psychotherapy with you. Rather, I am working with you as a transpersonal/spiritual counselor and folk healer of my ancestral lineage (Mexican traditional medicine). My ministerial license supports the spiritual nature of this work. It is my personal and professional ethic to hold all disclosures in the strictest confidence. My licensure as a minister precludes any participation in outside legal proceedings. This supports my intention to uphold our relationship as private and sacred.

RELEASE
I understand that Sylvia Poareo is working with me as a minister, not a licensed psychotherapist and that spiritual work may be a part of our work together. I understand that the time frame and outcome will largely depend upon my participation.

Signed by

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