1 General Information2 Intake and Personal Data3 Preliminary Questions4 Symptoms of Your Soul5 Agreement Name First Last Email What speciﬁc soul care intensives can I choose from?* Five Day Intensive: This intensive is designed for those who have recently experienced a life crisis and are seriously questioning the next steps involved. Three Day Intensive: This intensive involves those who desire to explore the deeper issues of life, but may not be in serious crisis or trauma but want to process the realities of life in a more authentic approach. One Day Intensive: This intensive is designed for those seeking practical tools for deepening one’s intimacy with God. This intensive will involve spiritual direction, prayer, scripture meditation, and some silence and solitude. (This intensive will only be available on a limited basis) Save and Continue Later Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Home PhoneCell PhonePhoneWebsite Are you married?yesnoFor 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/DrugReasonHow Long Please give the following info for each person that currently lives in your home, including yourself:NameAgeRelationship Please list any prescription psychiatric medicines you are currently taking:Doctor/DrugReasonHow Long 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 InformationName First Last PhoneRelationshipAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Save and Continue Later Brieﬂy describe what events/circumstances have led you to seek counsel and direction.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? Save and Continue Later Rank each question on a scale of 1 to 10. 1 = In need of help 5 = Fair 10 = ContentA constant feeling of hopelessness and despair12345678910Busy but bored12345678910Loss of control over life's routine12345678910Loss of spiritual connection and responsiveness to others12345678910Withdrawal from responsibility and leadership12345678910Preoccupation with projects of lesser importance12345678910Restlessness and dissatisfaction12345678910Resurgence of unhealthy habits, diminished impulse control and diminished resistance to temptation12345678910Guilt and shame12345678910A hard heart12345678910Aware of God’s presence in my life, conﬁdent of his love for me and feel connected to God12345678910 Save and Continue Later 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 to conﬁrm that you hereby agree to participate and attend a soul care intensive and to cooperate fully to the best of your ability.CommentsThis field is for validation purposes and should be left unchanged. Save and Continue Later This iframe contains the logic required to handle Ajax powered Gravity Forms.