ย  ย  ย PSSC SPIRITUAL SERVICES AGREEMENT
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Description of Project SPIRIT Sickle Cell (PSSC) Spiritual Services
The goal of PSSC services is to help you understand your personal spiritual development, while managing the many facets of exploring how spirituality may lead to your optimum health and well-being. You will meet one-on-one in a confidential caring way with a chaplain to discover and discuss any current struggles you may be facing. The chaplains are spiritual advisors such as pastors who will provide non-denominational spiritual support. ย Services are provided at ๐๐Ž ๐‚๐Ž๐’๐“ to you.
SPIRITUAL SERVICES AGREEMENT
In order to be fully informed about the spiritual services you will be receiving, please read through the following agreement, sign and date it at the bottom. This form must be electronically signed and returned to ๐๐’.๐๐‘๐Ž๐‰๐„๐‚๐“๐’๐๐ˆ๐‘๐ˆ๐“@๐†๐Œ๐€๐ˆ๐‹.๐‚๐Ž๐Œ.
We will provide you a copy of this digitally signed document.

WHAT PSSC, INC. OFFERS
Your commitment to the process will greatly determine the outcome of your experience. If you agree to be part of this program you will:
1) Have opportunities to explore your spiritual self a virtual session with a chaplain.ย 
2) Have time to discuss key issues related to coping including the concepts of hope
3) Gain an understanding for exploring how spirituality may lead to optimum health and well-being
4) Learn strategies for coping with life situations which may be a source of pain for your life.
5)ย Be given space for personal transformation and new awakenings for the importance of personal spiritual ownership.
6) Have opportunities to participate in virtual monthly group sessions
7)ย Complete a document created by young people your age, which will communicate to family, friends and health care providers in writing what makes you feel supported, what decisions bring you peace, what provides you the most comfort, and voice any other thoughts and needs for how you wish to be treated especially at times when you may not be able to speak for yourself.
๐–๐‡๐€๐“ ๐๐’๐’๐‚ ๐๐„๐„๐ƒ๐’ ๐…๐‘๐Ž๐Œ ๐˜๐Ž๐”
Your commitment to the process will greatly determine the outcome of your experience. As such you commit to the following actions:
1) Provide an email address and cell phone number to receive reminders of meeting sessions dates and times.

2)ย ย Complete a questionnaire to help us understand your thoughts and ideas about spirituality, both at the beginning and at the end of our time together.

3) ย Begin your sessions on time so we can end on time.
5) Notify your chaplain at least 24 hours before your scheduled appointment time if you need to cancel or reschedule a session.
6) Let your chaplain know at any time if you change your mind about participating in this spiritual intervention experience. ย 
7) Complete an evaluation questionnaire at the end of your time with PSSC about the services you received, whether they met your needs and provide suggestions for improvement.
Confidentiality
We follow guidelines provided by federal and state laws to protect your personal information. We will not share information with family, your doctor, or anyone else without your written authority.

Your chaplain will adhere to commonly accepted codes of privacy and confidentiality in counseling ethics. There are situations, however, in which the law requires that certain information can be revealed without your consent. Under the discretion of the chaplain, if there is any indication that you may be a danger to yourself or others, or involved in abusing a minor child, your information will be disclosed to appropriate sources as mandated reporters.

๐’๐ก๐จ๐ฎ๐ฅ๐ ๐ฒ๐จ๐ฎ ๐ก๐š๐ฏ๐ž ๐š๐ง๐ฒ ๐ช๐ฎ๐ž๐ฌ๐ญ๐ข๐จ๐ง๐ฌ ๐ฉ๐ฅ๐ž๐š๐ฌ๐ž ๐œ๐จ๐ง๐ญ๐š๐œ๐ญ ๐๐ซ๐จ๐ฃ๐ž๐œ๐ญ ๐’๐๐ˆ๐‘๐ˆ๐“ ๐’๐ข๐œ๐ค๐ฅ๐ž ๐‚๐ž๐ฅ๐ฅ's Programย Coordinator Tishaย ๐›๐ฒ ๐ž๐ฆ๐š๐ข๐ฅ, ย (๐ฉ๐ฌ.๐ฉ๐ซ๐จ๐ฃ๐ž๐œ๐ญ๐ฌ๐ฉ๐ข๐ซ๐ข๐ญ@๐ ๐ฆ๐š๐ข๐ฅ.๐œ๐จ๐ฆ) ๐จ๐ซ ๐ญ๐ž๐ฑ๐ญ (๐Ÿ๐Ÿ’๐ŸŽ.๐Ÿ•๐Ÿ–0.8986).



Your digital signature means that you understand the information provided to you in this form and you commit to these services.
Digital Signature of Participant (*Required) *
Participant Email *
Participant Cell Phone Number *
We look forward to working with you.ย 
Date Signed by Participantย 

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