THE HSWAGATA BUDDHA TOOTH RELIC PRESERVATION MUSEUM
FOR INTERNAL USE ONLY
Template No.: T142
Template Title: Spiritual Counselling Request & Referral Form
Related Research Case IDs / Cluster: Cluster B – Non-Human Guardians & Vocation (Cases 11–20)
Linked Templates / Policies: T132 (Spiritual Emergency / Disturbance Incident Log), T133 (Mentor–Mentee Assignment), T134 (Practice & Precepts Review), T136 (Wellbeing & Burnout Check-In), Duty of Care & Wellbeing Guidelines
Date of form: ____ / ____ / ______
Prepared by / Role: _________________________________
Office / Unit: _______________________________________
Country / Location: _________________________________
Confidentiality Level:
Internal only [ ] Restricted [ ] Sacred-Restricted / Sensitive [ ]
Use of this form (tick):
New case / action [ ] Follow-up [ ] Annual review [ ] Archive only [ ]
SECTION 1 – PERSON REQUESTING COUNSELLING
1.1 Basic details
-
Full name: _________________________________________
-
Dharma / monastic name (if any): ____________________
Status (tick):
[ ] Bhikkhu / Monk [ ] Bhikkhunī / Nun
[ ] Novice [ ] Lay male
[ ] Lay female [ ] Other: ______________________
Relationship to HSWAGATA (tick):
[ ] Core Relic Custodian
[ ] Assistant Custodian
[ ] Trainee Custodian
[ ] Security / guard
[ ] Guide / educator
[ ] Museum / admin staff
[ ] Volunteer
[ ] Visitor / retreatant
[ ] Other: __________________________________________
Main site / branch (if any): __________________________
1.2 Contact information
-
Phone: _____________________________________________
-
Email: _____________________________________________
Preferred way to contact you:
[ ] Phone [ ] Email [ ] Messaging app: ___________
Times when you are usually free (e.g. evenings, mornings):
SECTION 2 – MAIN CONCERN (BRIEF DESCRIPTION)
This form is for gentle spiritual counselling and support.
Please use simple words. You do not need to write long detail.
2.1 Type of concern (tick all that apply)
Vocation and guardianship
[ ] Questions about my calling / vocation
[ ] Doubts about being a relic custodian
[ ] Conflict between duty and family / other roles
Practice and inner life
[ ] Feeling stuck in meditation or practice
[ ] Trouble keeping precepts or discipline
[ ] Confusion about dreams / signs / guardians
Wellbeing
[ ] Stress, tiredness, or near burnout
[ ] Anxiety, worry, or fear
[ ] Sadness or low mood
Relic / shrine context
[ ] Fear or confusion linked to relics / shrine space
[ ] Strong experience in vigil or ceremony
[ ] Other shrine-related concern: ________________
Other
[ ] Relationship / community problem
[ ] Other concern (please name): _________________
2.2 Short description of concern (3–8 lines)
Please write in your own words, briefly:
2.3 How long has this been a concern?
[ ] Just today / very recent
[ ] Days to weeks
[ ] A few months
[ ] More than 6 months
SECTION 3 – PREFERRED COUNSELLOR / SUPPORT PERSON
3.1 Preference
Do you have a preferred counsellor or support person?
[ ] No strong preference – anyone suitable is ok
[ ] Yes – I prefer this person (write name):
________________________________________________
3.2 Type of counsellor preferred (tick any)
[ ] Monastic (monk / nun)
[ ] Senior lay practitioner
[ ] Mentor already assigned to me (T133)
[ ] Wellbeing / duty of care officer
[ ] Other: __________________________________________
3.3 Language and gender preferences
Preferred counselling language(s):
Gender preference (if important for you):
[ ] No preference
[ ] Prefer male counsellor
[ ] Prefer female counsellor
[ ] Other: __________________________________________
Short note if there is a reason for this preference (optional):
SECTION 4 – APPOINTMENT TIME & MODE
4.1 Urgency (self-view)
How urgent does this feel for you?
[ ] Normal – I can wait for the next free slot
[ ] Sooner – I hope to meet within 1–2 weeks
[ ] Urgent – I hope to meet within a few days
[ ] Very urgent – I feel unsafe / very unstable
(If “Very urgent”, please also inform duty officer now.)
4.2 Preferred mode of counselling
[ ] In-person meeting at HSWAGATA site
[ ] Online video call
[ ] Phone call
[ ] Other: __________________________________________
4.3 Preferred days and times
Please tick and/or write times that are possible for you:
Days:
[ ] Monday [ ] Tuesday [ ] Wednesday
[ ] Thursday [ ] Friday [ ] Saturday
[ ] Sunday
General time:
[ ] Morning
[ ] Afternoon
[ ] Evening
If you have more exact times, write here:
4.4 Any time limits or access needs
(e.g. must return to work by certain time, need ground-floor room, need translator, etc.)
SECTION 5 – SAFETY & SUPPORT CHECK
This part helps us see if extra support is needed. Use simple words.
5.1 Current safety
Right now, I feel:
[ ] Mainly safe, just need guidance
[ ] Very stressed, but still safe
[ ] Not sure if I am safe
[ ] In danger or very unsafe (please explain briefly and speak to duty officer or trusted person today):
Short note (if you ticked “Not sure” or “In danger”):
5.2 Other supports
Are you already receiving support from anyone?
[ ] No
[ ] Yes – mentor (T133)
[ ] Yes – spiritual teacher / preceptor
[ ] Yes – counsellor / therapist
[ ] Yes – doctor / health worker
[ ] Yes – family or friends
[ ] Other: __________________________________________
Short note if you wish:
5.3 Permission to coordinate support
May HSWAGATA counsellors, with care, speak with your mentor / teacher / health worker if needed for your safety (only when really needed)?
[ ] Yes, I agree
[ ] Yes, but please ask me first each time
[ ] No
SECTION 6 – CONSENT & PRIVACY
6.1 About spiritual counselling at HSWAGATA
I understand that:
-
Spiritual counselling offers listening, Dhamma-based guidance, and support.
-
It is not a promise of miracles or special powers.
-
Counsellors are bound by confidentiality, but must act if there is serious risk of harm to me or others.
6.2 Use of this form
I agree that:
-
The information on this form may be used by the spiritual counselling / wellbeing team to arrange support.
-
Notes may be stored securely as part of my file in line with HSWAGATA policies.
[ ] Yes, I agree
[ ] No (note: if “No”, we may not be able to arrange a formal appointment)
6.3 Declaration
I have answered honestly, as far as I can today.
Name (print): ________________________________________
Signature (or mark): __________________
Date: ____ / ____ / ______
SECTION 7 – FOR OFFICE USE – TRIAGE & REFERRAL
(To be filled by counsellor / wellbeing staff.)
7.1 Received by
Name: _______________________________________________
Role: _______________________________________________
Date received: ____ / ____ / ______
Time: _____________________
7.2 Initial assessment (short)
Urgency level (staff view):
[ ] Routine
[ ] Soon (within 1–2 weeks)
[ ] Urgent (within a few days)
[ ] Emergency (same day response; refer to T132 / health services)
Short note:
7.3 Assigned counsellor / support person
Name: _______________________________________________
Role: _______________________________________________
Reason for this choice (short):
7.4 Appointment scheduled
-
Date: ____ / ____ / ______
-
Time: _____________________
-
Mode:
[ ] In-person [ ] Online [ ] Phone [ ] Other: ______
Place / link / phone number:
7.5 Notes on referral
Referred also to (tick if yes):
[ ] Mentor (T133)
[ ] Spiritual teacher / preceptor
[ ] Doctor / clinic
[ ] Counsellor / therapist
[ ] Emergency / crisis service
[ ] Other: __________________________________________
Short note:
SECTION 8 – ARCHIVING & LINKS
8.1 File storage
-
Physical file code / folder: _________________________
-
Digital archive path / ID: __________________________
8.2 Linked records
[ ] T133 – Mentor–Mentee Assignment Form
[ ] T134 – Individual Practice & Precepts Review Sheet
[ ] T136 – Wellbeing & Burnout Check-In Form
[ ] T132 – Spiritual Emergency / Disturbance Incident Log (if any)
[ ] Retreat or training file: _________________________
[ ] Other: ___________________________________________
