Welcome!

Thank you for reaching out. I look forward to working together. I wanted to share some practical
information with you about our time together. If you have any questions, please don’t hesitate to
ask.

HOW I WORK The agenda in our meetings is client generated and practitioner
supported – which means that you will bring the issue you want to
work on and we will explore it together.

SCHEDULING We are both committed to being on time for the start of the session;
and…we live in the real world! If you are late, I will, in most cases,
only be able to sit with you until the end of our scheduled time.

EXTRA TIME You may contact me between sessions if you need brief support with
self-regulation or can’t wait to share an achievement with me. I enjoy
delivering this extra level of service. I do not bill for additional time of
this type, but I ask that you please keep the extra contact brief. When
you leave a message via phone, please let me know if you want a call
back or if you are just sharing.

CHANGES Please give me 24 hours’ notice if you have to cancel or reschedule a

session. If you have an emergency, we will work around it. Otherwise,
you will need to pay for missed sessions.

FEE I accept payment by Venmo, Zelle, or, if we work in person, a

personal check in US$. I prefer electronic payment, and it’s easiest if
you pay right before our meeting so neither of us has to remember.

CONFIDENTIALITY Whatever you bring up during our sessions will be held in confidence
unless you state otherwise in writing, except as required by law.

Igal Harmelin ● www.igalharmelin.com ● (413) 841-5911

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Informed Consent

1. I, Igal Harmelin, am offering you, the client, sessions of spiritual direction. I am a certified spiritual director
and meditation teacher. I am also certified to practice NARM (Neuro Affective Relational ModelTM), a
healing modality for developmental trauma. I am neither a licensed therapist, nor a licensed psychologist,
nor a licensed physician, and I do not practice psychotherapy. I do not diagnose or treat mental illness.

2. You understand that sessions with me do not treat mental disorders as defined by the American Psychiatric
Association. You understand that sessions with me are not a substitute for counseling, psychotherapy,
psychoanalysis, mental health care, medical care or substance abuse treatment and you will not use them
in place of any form of therapy or medical intervention.

3. If in the course of our work together I will determine that working with you is outside the scope of my
competence and/or training, I will either refer you out to, or ask to work in collaboration with, an appropriate
mental health professional.

4. If you are currently in therapy or otherwise under the care of a mental health professional, you declare that
you have consulted with this person regarding the advisability of working with an alternative practitioner and
that this person is aware of your decision to proceed with the relationship.

5. You, as a client, agree that you are fully responsible for your well-being during your sessions with me,
including your choices and decisions. Sessions with me may involve all areas of your life, including work,
finances, health, relationships, education and recreation. You acknowledge that deciding how to handle
these issues and implement your choices is exclusively your responsibility.

6. You understand that sessions with me are not to be used in lieu of professional advice. You will seek
professional guidance for legal, medical, financial, business, or other matters. You understand that all
decisions in these areas are exclusively yours and you acknowledge that your decisions and your actions
regarding them are your responsibility.

7. If you are uncomfortable with any aspect of the sessions you attend, it is your responsibility to say so. If you
have any questions about your work with me, please ask, and I will do my best to answer your questions in
full. You have the right to refuse or terminate sessions, and/or to refuse to have sessions, at all times, or to
refuse any intervention I may propose or employ.

8. All matters discusses during our sessions will be held in confidence, except as required by law. Please
note, however, that spiritual directors and NARM practitioners do at times consult with professional
colleagues who are bound by the same rules of confidentiality.

----------------------------------------------------------------------------------------------------------------

I have read the above Informed Consent, understand it, and ask to engage in spiritual direction with Igal
Harmelin.

______________________ _______________ ____________________

Client Signature Date Client name (please print)

Igal Harmelin ● www.igalharmelin.com ● (413) 841-5911

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 Client Information
Date: _______________________

Name: ______________________________________________________________________________________

Occupation: __________________________________________________________________________________

Mailing Address: _______________________________________________________________________________

Home Phone: _________________________ Cell Phone: ____________________

E-mail Address: ___________________________ Preferred means of communication: _______________________

Date of Birth: __________________________ Age: _________________

May I add you to my email list (I never share my list)? Yes______ No_________

Emergency Contact (name, relation to you, one or more phone numbers, and possibly an email address:

____________________________________________________________________________________________

Other information you want me to know: (You may continue on back of page.) ______________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

What influenced your decision to work with me? ______________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

Have you ever worked with a Spiritual Direction and/or a practitioner of NARM? If so, what was your experience?

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

Do you have specific goals for this work? If not, what goals might you now create? __________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

Who were you referred by? ______________________________________________________________________

Igal Harmelin ● www.igalharmelin.com ● (413) 841-5911

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