Sojourn Care Request Form Question Title * 1. Contact info: Name Address Address 2 City/Town State/Province ZIP/Postal Code Email Address Phone Number Question Title * 2. Date of Birth: Date / Time Date Question Title * 3. If married, date of marriage: Date / Time Date Question Title * 4. If separated, date of separation: Date / Time Date Question Title * 5. If divorced, date of divorce: Date / Time Date Question Title * 6. Church membership status: Member Member in process - awaiting interview Member in process - signed up for class Sunday attendee Searching for a church home Question Title * 7. Are you in any sort of Christian accountability/community/care group? I Question Title * 8. Reason for seeking care: Life struggle Crisis situation Marriage Family Question Title * 9. When did your present concern begin to be a problem for you? Briefly describe why you are seeking care: Question Title * 10. Where are your concerns causing the most problems for you? Home Work Marriage Other relationships God Other (please specify) Question Title * 11. Have you spoken to a Sojourn elder or other church leader about this issue? Yes No Question Title * 12. If you have spoken to a Sojourn church leader, please state their name: Question Title * 13. Do we have your permission to share this information with the appropriate ministry leaders to arrange for the best possible care? Yes No Question Title * 14. Marriage counseling - if married, does your spouse know you are seeking help? Yes No Question Title * 15. Marriage counseling - is your spouse willing to come? Yes No Not sure Question Title * 16. Family counsel - what are the names and ages of children involved? Question Title * 17. Have you had professional counseling? Yes No Question Title * 18. If yes, please elaborate including name of counselor, year(s), number of sessions and lessons learned. Done
