Emotional and Spiritual Support Sign-Up

If you feel you are having an IMMEDIATE medical or mental health emergency, dial 911 (in the United States and Canada), or 100, 101, or 102 (in Israel).

* Required

First Name *
 

Last Name *
 

Phone *
  ext.   

E-mail *
 

WhatsApp
 

Preferred Contact Method *
 

In case of an emergency, please identify one (1) person (First Name, Last Name) who RUACH may contact. RUACH will not share any personal information unless granted your permission. You may discuss this with your caregiver. *
 

Emergency Contact Phone Number *
  ext.   

Pronouns *
 

What is your age range? *
 

Where are you living (state/province)? *
 

What is the faith that you feel most aligned with? *
 

What type of conversation are you interested in? Select all that apply. *
 

Please tell us what you would like to talk about so we can help facilitate a connection between you and a caregiver in our network. Please include any preferences for a caregiver (e.g., gender identity, trauma/domestic violence/crisis intervention skills, LGBTQ+ affirming, etc) Please also include current stressors related to COVID19 (e.g., isolation, spiritual needs, job loss, grief-related loss, emotional distress and other disruptions, etc.) *

We conduct our sessions over video conferencing or phone. Will you need any special accommodations to be able to speak with your supporter using this technology? *
 

Do you have insurance that could help cover emotional or spiritual care? Although our service is 100% free and no insurance is required, we ask about insurance to know your health care situation and be able to provide relevant referrals. *
 

Are you currently under the care of an emotional or spiritual care provider (e.g., mental health professional, member of clergy or other spiritual care)? If so, please briefly explain your current situation. If not, please write "no". *

A caregiver will contact you within 48-72 hours Monday - Friday. If you prefer sooner, please indicate. For immediate help, please call a 24/7 hotline listed above. *
 

How did you find out about our service? If personal contact or organization, please add name in the "Other" box. *

Other

 

Please type your initials to acknowledge that you have read the Terms and Conditions: "RUACH DOES NOT provide mental health, medical or other therapeutic care. RUACH works to connect those in need of emotional and spiritual support with volunteer-supporters. Services provided by RUACH are not a substitute for mental health care, therapy, or psychological or medical services." *
 

Please type initials to acknowledge that you read the wavier of liability: "RUACH: Emotional and Spiritual Support (“RUACH”) is a volunteer, non-profit service. You hereby release and waive any and all claims of any nature that you may have at any time against RUACH, its founders, managers and administrators, officers, directors, employees, and agents, or against volunteer-supporters (collectively, the “Released Parties”), resulting from any acts or omissions of any Released Party related to or arising out of services provided as described in these Terms and Conditions, excluding claims resulting from the intentional misconduct or gross negligence of a Released Party." *
 

In order to receive services through RUACH: Emotional and Spiritual Support, please acknowledge that you have read and agree to these terms and conditions by writing an electronic signature (first name and last name) and date (XX/XX/XXXX) below: *

Please choose if you would like to be included in a study based on this project. Participation in the study is completely separate from participation in the project and will not impact your ability to gain emotional and spiritual support. *