Client’s Rights/Informed Consent for Spiritual Direction

Spiritual direction & companionship administered by Heart Speaks to Heart and Dr. Alberto Varona is spiritual, listening and prayer ministry and not counseling or psychotherapy sessions. Although Dr. Varona is a psychologist, he will only conduct formal psychotherapy work if an explicit agreement is made for psychotherapy beforehand and a different consent form is read and signed. At this time, psychotherapy services provided by Dr. Varona are supervised by Dr. Eunice Kim (071006918 Illinois)

Heart Speaks to Heart and Dr. Alberto Varona do not keep detailed records and will not provide information for lawyers, or disability claims, or for similar matters. All personal files and discussions are protected as “CONFIDENTIAL”. The exceptions to this confidentiality are:

  • As required by subpoena or court order in legal proceedings
  • When not to do so would potentially result in physical harm to myself or others
  • To report any disclosure/suspicion of child/elderly abuse (physical, mental, or sexual)

I give my permission for my Spiritual Director to discuss my spiritual/prayer needs with Dr. Eunice Kim, who is bound by confidentiality as stated above. Dr. Kim’s main role in this consultation is to make sure that no formal psychotherapy is being conducted and to verify whether or not a clinical consultation is necessary. If it is deemed necessary, there may be a recommendation for further treatment with a licensed counselor. Names and specific identifying information will not be routinely discussed/disclosed except where referral to other care/treatment is indicated. 

I also understand that I am protected from any sexual advances or harassment while undergoing spiritual direction sessions. If at any time I feel offended by anything my Spiritual Director asks, says, or does, I acknowledge that it is my responsibility to tell him. If the behavior does not stop immediately, and if the circumstances of the offensive words/actions are such that I am uncomfortable confronting the Spiritual Director, I also acknowledge that it is my responsibility to report it immediately to Dr. Eunice Kim. Professional liability insurance is provided by Ace American Insurance Company and covers wrongful employment practices. 

I also understand that at times there may be occasions that the Spiritual Director must cancel an appointment due to extenuating circumstances. All effort will be made to give me 24 hours notification of a necessary change. In the event that the Spiritual Director must cancel without advanced notice, I agree to either reschedule my appointment or take the next available appointment time. I also agree to give the Director 24 hours notice if I need to cancel or change an appointment, unless extenuating circumstances prevent me from doing so. In that situation, I will call and reschedule as soon as I am able. I understand that Heart Speaks to Heart and Dr. Alberto Varona are offering spiritual direction for a fee of $75 (with additional fee of $25 for home visits). I agree to pay this fee at the time services are rendered unless otherwise arranged prior to the session.

 

Signature:        ______________________________________

 

Date:                ______________________________________