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Sojourn Care Request Form

1.Contact info:
2.Date of Birth:
Date / Time
3.If married, date of marriage:
Date / Time
4.If separated, date of separation:
Date / Time
5.If divorced, date of divorce:
Date / Time
6.Church membership status:
7.Are you in any sort of Christian accountability/community/care group? I
8.Reason for seeking care:
9.When did your present concern begin to be a problem for you? Briefly describe why you are seeking care:
10.Where are your concerns causing the most problems for you?
11.Have you spoken to a Sojourn elder or other church leader about this issue?
12.If you have spoken to a Sojourn church leader, please state their name:
13.Do we have your permission to share this information with the appropriate ministry leaders to arrange for the best possible care?
14.Marriage counseling - if married, does your spouse know you are seeking help?
15.Marriage counseling - is your spouse willing to come?
16.Family counsel - what are the names and ages of children involved?
17.Have you had professional counseling?
18.If yes, please elaborate including name of counselor, year(s), number of sessions and lessons learned.