This is the person I will contact if I have a concern about your wellbeing or the wellbeing of others.
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Local Emergency Contact - Relationship *
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Spouse/significant other
Parent
Sibling
Close friend
Other (Please specify)
Local Emergency Contact - Telephone *
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Education
Current Profession or Vocation *
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Employer
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Sexual Orientation *
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Gender Identity/pronouns *
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I am currently... *
Please list current health concerns and history for significant accidents, surgeries, illness or medical hospitalizations: *
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Please list current Medications/Supplements/Herbs: *
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What substances do you partake in regularly? *
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Tell me about your relationship with the above substance(s) (if any) Any history of addiction? *
I request that you do not attend an appointment with me while under the influence of any non-prescription mind-altering substances.
Your answer
Are you attending a UU Congregation? *
Since I am fellowshipped as a UU minister, I need you to tell your minister (if you have a UU minister) that you are pursuing spiritual direction with me.