Your full name:
Your email address: (e.g.: you@aol.com)

Your company:

Your phone number (with country, city, area codes):

Mailing Address:
City/Town/State/Zip:	State/Prov.: Post./Zip Code:
Country:

Which of the options listed below describes the general nature of your request (check off as many as apply)

Help with prayer and spiritual discipline
Grief . . . loss.
Struggle with relationship
Questions about theology, religious beliefs
Addiction/recovery issues
Kundalini, spiritual emergency issues.
Other

Which spirituality consultant would you like to work with?

Philip St. Romain, M.S., D. Min.
Mary Rees
Rev. Connie Burkholder
Rev. River Sims
Cindy Maslin
Kathy Goetz OP
David Rothstein, Ph. D.
Monique Keffer

In submitting this request, I acknowledge that Heartland Center for Spirituality is legally responsible only for the actions of those spiritual directors (Philip St. Romain, Connie Burkholder and Renee Dreiling, OP) in its employ. All other directors listed have indicated both competence and experience in their listing applications, but they are not members of the Heartland Center for Spirituality team, and Heartland Center cannot be held responsible for their actions.