PC Declaration Form
Spiritual Counseling Declaration
All students and recipients of Spiritual Counseling should carefully read the following points and
sign the declaration below. This declaration should be witnessed by a notary.
I swear I am undertaking spiritual counseling with a desire to improve myself and for no other reason.
I acknowledge and fully realize that any services offered by the spiritual guidance counselor are not the
approved Services of Scientology and Dianetics nor those offered by the Church of Scientology
I fully understand that the practitioner is neither endorsed by, or associated or affiliated with, the
corporate company known as the Church of Spiritual Technology or its companies and churches such as
the Religious Technology Centre, Church of Scientology International, or any other of its affiliates,
corporations management organizations or groups and in fact disavow any connection with that
I fully understand and realize that by undertaking this spiritual counseling I may be refused any further
services by the Church of Scientology International.
I fully understand that the services of spiritual counseling and/or training I will undertake are based on
the ideas of various philosophers and thinkers, including Lafayette Ron Hubbard.
No promises or guarantees are made regarding any spiritual counseling given and no results are implied
or guaranteed. The counseling being offered and received is of a spiritual nature only and everything is
done on a "best effort basis."
Any payment agreed upon and made is solely for compensation for the time of the spiritual guidance
counselor and not for any services or materials rendered.
Any and all payments made to the spiritual guidance counselor are non refundable as it is a payment for
the time of the practitioner and not for any services rendered.
I swear, under penalty of perjury, that I am not an agent, now or will be in the future, for the corporate
company known as the Church of Spiritual Technology or any of its companies and churches such as the
Religious Technology Centre, Church of Scientology International, or any other of its affiliates,
corporations management organizations or groups.
I swear that I have either departed from the Church of Scientology of my own volition if I was a
member, or have no intention to be a member if I was not ever a member.
I swear I am seeking spiritual counseling for my own benefit and not for the benefit of others.
I swear I am not seeking any services as an alternative, competitive or otherwise, to services delivered
by the Church of Scientology .
I acknowledge that the spiritual guidance counselor does not deliver any services as an alternative,
competitive or otherwise, to services delivered by the Church of Scientology, but provides individual
spiritual guidance only on a hourly basis.
I swear I am not here to seek any treatment or therapy for any physical or mental condition and will not
be receiving any treatment or therapy for any physical or mental condition. If it is found that I am
suffering from any physical or mental illness, the practitioner reserves the right to refuse spiritual
counseling at his or her discretion.
I swear I am not under any psychiatric or medical therapy or treatment and am not taking any medical or
I acknowledge and agree that I can be refused spiritual counseling if the practitioner believes they
cannot honestly provide it.
I, the undersigned, declare that I fully understand and agree to all of the points above.
Declared. ________________________________________date _______________
Print your name ___________________________________date_______________
Notarized. _______________________________________date _______________
Stamp or seal of notarizer here: