02/25/2026
INTAKE & SPIRITUAL CARE AGREEMENT
Office of [Name], Mr. Shatoctga Maurice G Bey Ph.D., HHP
Ordained Minister | Shamanic Practitioner | Pastoral Care Therapist
1. CLIENT INFORMATION
Name: _________________________________________________ Date: _______________
Address: __________________________________________________________________________
Phone: _________________________ Email: _________________________________________
Emergency Contact: _________________________________ Phone: ____________________
2. FOCUS OF VISIT
What is your primary goal for today’s session?
[ ] Shamanic Journeying / Indigenous Wisdom
[ ] Pastoral Counseling / Spiritual Guidance
[ ] Holistic Wellness / Natural Health Mentorship
[ ] The Cosmetic Mind (Philosophy & Self-Management)
Briefly describe your current spiritual or wellness needs:
3. PROFESSIONAL DISCLOSURE & LEGAL DISCLAIMER
Please read and initial each point:
ECCLESIASTICAL STANDING: I understand that [Name] is a twice-ordained Minister (2003/2017) and holds a Ph.D. in Metaphysics and a Master of Pastoral Counseling. These are religious/ecclesiastical credentials, not secular academic degrees. _____
NON-MEDICAL/NON-CLINICAL: I understand that [Name] is a Pastoral Care Therapist and Holistic Health Practitioner (HHP). He is NOT a state-licensed medical doctor, psychiatrist, or clinical psychologist. He does not diagnose or treat medical or mental disorders. _____
SOVEREIGN WISDOM: I acknowledge that the services provided are based on 17 years of original research, indigenous shamanic traditions, and the "Cosmetic Mind" philosophy. _____
CONFIDENTIALITY: All sessions are conducted under the sacred trust of the Ministry. Information is confidential unless there is an immediate risk of harm to self or others. _____
4. INFORMED CONSENT
I, ________________________________ (print name), voluntarily choose to engage in spiritual/holistic services with [Name]. I understand that these services are intended to support my spiritual well-being and personal growth through a humanistic and shamanic approach. I take full responsibility for my own health and well-being.
Signature: _____________________________________________ Date: _______________
INTERNAL USE ONLY (Practitioner Notes)
17-Year Research Context / Shamanic Observations:
Would you like me to create a "Certificate of Completion" or "Recognition of Journey" that he can give to clients after a major shamanic session?