Soul Care Intensive Application

PERSONAL INFORMATION

* Indicates required field

Name *

First

Last

Email *

Phone Number *

Address *

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City

State

Zip Code

Country

Website *

Are you married? *

Yes No

If so, how long? *

If you have previous marriages, how many? *

If your parents are divorced, how old were you? *

Please list any prescription psychiatric medicines you are currently taking: (doctor/drug/how long): *

Please list the following info for each person who currently lives in your home, including yourself (Full Name/Age/Relationship): *

If you have any current or expected legal involvement, please explain: *

If you are currently under an order of protection, please explain: *

If you currently attend a church, which one? *

EMERGENCY CONTACT INFORMATION

Name *

First

Last

Phone Number *

Email *

Relationship *

Address *

Line 1

Line 2

City

State

Zip Code

Country

PRELIMINARY QUESTIONS

Brieﬂy describe what events/circumstances have led you to seek counsel and direction? *

What speciﬁc soul care intensive are you most interested in?* *

5 Day Intensive 3 Day Intensive 1 Day Intensive

Please list 2-3 dates you would be interested and available to participate in a Soul Care Intensive. *

In what areas of your life do you seemingly see God as distant or absent? *

In what areas of your life do you sense God most wants to speak to? *

What have been a few of the most memorable moments that have shaped your life? *

What are some of the big obstacles in your life keeping you from becoming more like Christ? *

AGREEMENT

This form answers conﬁdential/privacy concerns that participants usually have when they begin a Soul Care Intensive. It will also outline brief guidelines and privacy policies. After reading this document, please feel free to ask any questions that you may have. You will be asked to sign and send a copy back to us. You also may want to retain a copy for your records.

Conﬁdentiality: All statements made during your Soul Care Intensive will remain conﬁdential. The information you disclose cannot be shared with others, except if there becomes a need for a professional consultation with a colleague in reference to your situation. The exceptions to this rule would be if: 1. you have signed an authorization allowing us to disclose information; 2. you are in present danger of harming yourself or others 3. you are petitioned by the court for your records 4. there is an issue of child, elder, or dependent adult abuse. Release of information to other individuals, agencies or professionals may only be done with your written consent.

Emergencies: Though soul care intensives are not always crisis oriented in nature, there still may be a need for referral. If you feel you will need more intensive hours and support on a regular basis, please inform your soul care provider so an appropriate referral may be made. Each one of our soul care providers are in contact with licensed professional therapists and will provide you with various options as it pertains to your current need and situation.

In the event of an emergency please call 911.

Confirmation *

*Enter your name above to conﬁrm that you hereby agree to participate and attend a Soul Care Intensive and to cooperate fully to the best of your ability.

Submit

Apply for a Soul care intensive

PERSONAL INFORMATION

EMERGENCY CONTACT INFORMATION

PRELIMINARY QUESTIONS

AGREEMENT