Spiritual Support Palliative Care Consent Form
Patient Information
Full Name
Date of Birth
Patient ID / MRN
Spiritual Support Details
Preferred Faith/Spiritual Tradition
Requested Spiritual Leader or Counselor
Types of Support Requested (e.g., prayer, rituals)
Consent
I consent to receive spiritual support as part of my palliative care.
I allow relevant information to be shared with spiritual care providers.
Additional Notes or Requests
Signatures
Patient/Representative Signature
Date
Witness/Staff Signature
Date