Clients Rights/Informed Consent for Spiritual Direction

I, ___________________________ (print name), understand that spiritual direction administered by The Chara Group is spiritual/ prayer ministry and not counseling or therapy sessions. The Chara Group does not keep detailed records and will not provide information for lawyers, or disability claims, or for similar matters. I further understand that my personal files are protected as CONFIDENTIAL. As such, identifying, specific details of my file may not be disclosed to others without my written consent except as specified by Georgia law: 1. 2. 3. 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 also understand that this ministry uses services of trained Spiritual Directors and not licensed Counselors (unless otherwise specified). As such, the Spiritual Directors are required to consult periodically with Angel H. Davis, LCSW, BCPCC, and founder of The Chara Group. I give my permission for my Spiritual Director to discuss my spiritual/prayer needs with Angel Davis as necessary. Angel H. Davis is bound by confidentiality as stated above. 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. If I have any questions concerning my Spiritual Directors training, experience, or qualifications, I have a right to inquire about this to the Spiritual Director or to Angel H. Davis. I agree to hold The Chara Group and its Spiritual Directors free from any and all liability, loss, or damage of any kind that may arise as a result of assistance that I have received, or from my involvement with, The Chara Group. 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 or her. 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 Angel H. Davis. 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 The Chara Group is offering spiritual direction for a fee of $50 per hour. I agree to pay this fee at the time services are rendered unless otherwise arranged prior to the session.

______________________________________ Signature (of parent/guardian if under 18 years)

_______________________________________ Date

______________________________________ Witness

_______________________________________ Date