Lee’s Covenant Form Name * First Name Last Name Email Address * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Primary Phone Number * (###) ### #### Contact Preference * How do you preferred to be contacted? Email Text Phone Call How Did You Learn About My SD Practice? * If you were referred by someone, please list their name in your answer. Emergency Contact Information Emergency Contact Name First Name Last Name Email 1 * Cell Phone * (###) ### #### Does this person know you are in Spiritual Direction? * Yes No In case of contact, may I let them know that I am your Spiritual Director * Yes No Other Professional Contacts If you would like me to be in contact with an additional LPC or other, please fill out the below information Other Professional Name First Name Last Name Other Professional Email Address Other Professional Phone (###) ### #### I give my consent to Lee Jarrell to be in consultation with this professional on my behalf. Yes No Thank you!
