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Shalom Place

 
Information About Applicant

Please fill out the form below, responding to all questions you are comfortable sharing with us. If you do not want to submit the form through the Internet, then print it out and mail to: Spiritual Direction. Heartland Center for Spirituality. 3600 Broadway. Great Bend, KS 67530..

Name

Street Address or P. O. Box
. . . . . . .(Apartment Number)

City/State-Province/Zip

Country

E-mail Address

Web Site URL (if any)

Telephone # (include area code)

Place of Employment
. . . . . .Occupation

Birthday

I am . Single. Married. Divorced. Separated
. ... .. . . Widowed. Clergy. Religious

Religious body/church affiliation:

How much time do you give (on the average) to your inner life (e.g., prayer, meditation, journaling, silence, study, dream work, etc.)? Explain briefly below:

What is your previous experience with spiritual direction, counseling, or therapy? Describe below.

Do you have a physical or psychological health problem we should know about? If so, please explain below:

What is your motivation for seeking spiritual direction at this time? Please explain below:

Listed below are some approaches to spiritual growth which many have found helpful. Please check those you are familiar with and/or your desire to become familiar:

Topic
Am Familiar
Want to Learn

Dreamwork

Inner Child

Centering prayer

Focusing

Contemplative sitting

Scripture meditation

Guided Imagery

Eastern Spirituality

Charismatic Renewal

Creation Spirituality

12 Step Spirituality

Feminine Spirituality

Enneagram

Spirituality of the mystics
Other area(s) of familiarity


Which spiritual director would you like to meet with?
- see this page to read about them all, or click on the links to each below.

Philip St. Romain | Mary Rees | Rev. River Sims | Cindy Maslin | Kathy Goetz OP | David Rothstein | Rev. Connie Burkholder | Monique Keffer

. . . First choice
. Second choice

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.