Filling out the form below is the first step in booking your counseling appointment.

After you've submitted the form below, do the following:

  1. Email Dods Pengra at dods@sojournheights.org on how to schedule your session.

  2. Visit pushpay.com/pay/sojournheights to pay the requested donation for your session.

    • The requested donation for Covenant Members of Sojourn Heights is $40.

    • For non-Covenant Members - $90.

    *Because you are receiving a service for your donation, it is not tax-deductible.

    **Donations are non-refundable

INTAKE FORM

PERSONAL INFORMATION
Name *
Name
Phone Number *
Phone Number
Address *
Address
If Married, when did you get married?
If Married, when did you get married?
Spouse's Name (if applicable)
Spouse's Name (if applicable)
Spouse's Phone Number
Spouse's Phone Number
MEDICAL INFORMATION
ASSESSMENT
From the follow list, please select all that apply to you and rate the severity from 1 (infrequently present) to 5 (always present). Use the comment section below to explain in more detail, if necessary.
Emotional Well-Being *
Emotional Well-Being
I feel depressed
I feel fearful
I feel angry
I feel sad
I feel worthless
I feel anxious
I feel hopeless
I feel overwhelmed
I feel bitter
I feel rejected
Financial Well-Being *
Financial Well-Being
I do not enjoy work
I am struggling financially
Relationships *
Relationships
I am easily hurt by others
I have difficulty maintaining friendships/relationships
I have trouble making friends
I experience social anxiety
I have conflict with friends/coworkers
Struggles (Substance Abuse & Disorders) *
Struggles (Substance Abuse & Disorders)
I abuse alcohol
I abuse prescription drugs
I use illegal drugs
I view pornography
I struggle with body image
I struggle with bulimia
I struggle with anorexia
Marriage & Sex *
Marriage & Sex
I do not identify with my birth gender
I am attracted to my same-sex
I enjoy sex with my spouse
I do not enjoy sex with my spouse
I am not having sex with my spouse
I am having sex outside of marriage
I think about having sex outside my marriage
I do not love my wife
I do not respect my husband
I love my wife
I respect my husband
I am a poor communicator
My spouse is a poor communicator
Family & Parenting *
Family & Parenting
If the below does not apply, select NEUTRAL.
I enjoy being a parent
I do not enjoy being a parent
I have difficulty with my spouse’s family
I have difficulty with my family
Physical & Emotional Abuse *
Physical & Emotional Abuse
I have been physically abused
I have been sexually abused
I have been verbally abused
I have been physically abusive
I have been sexually abusive
I have been verbally abusive
Faith & Disciplines *
Faith & Disciplines
I read my bible daily
I read my bible weekly
I read my bible monthly
I do not read my bible often
I am a member of a local church
I attend the gathering of a local church
Jesus is my life
Jesus is important in my life
I do not think about Jesus often
Informed Consent & Counseling Disclosure
Please read the entire disclosure below, and mark that you understand the content before scheduling your counseling session. *
*All information contained in this intake form is strictly confidential and will not be shared beyond the counseling team at Sojourn Heights Church* In an effort to make informed decisions about your counseling experience and expectations, the following paragraphs are provided in order to discuss pertinent information regarding your counselor’s background and qualifications as well as your responsibilities as a client. “I, the undersigned, understand that any person I meet with for counsel through Sojourn Heights Church is not a licensed professional counselor. They will not be working toward a diagnosis as set out by the American Psychological Association. I have come seeking biblical counseling that will be conducted in a confidential setting." If you have any questions or concerns regarding any of the policies or statements made within this document, please email Dods Pengra at dods@sojournheights.org. Your counselor’s method of counseling is based on biblical truth. As a Christian, biblical counselor they believe in the triune God of the Bible who sent the Son, Jesus, empowered by the Holy Spirit, to live, die, and be raised for the atonement of our sin. Our counsel is shaped by these principles: 1) It is rooted in God and His Word 2) It exalts Jesus Christ and His Gospel 3) It is empowered by the Holy Spirit 4) It is loving. If you are willing, your counselor is eager to work with you, regardless if you share this view of God or counseling. There is always a risk of emotional or relational turmoil that could result from counseling. Counseling can bring up painful emotions or memories, or it could expose hurtful and damaging patterns of sin (in ourselves and/or others). At times, feelings and situations can worsen before they improve. Our goal is to address these issues and emotions biblically; to work through them with truth and care in a timely manner. While the length of counseling is difficult to predict, we recommend all who seek counseling to commit to no less than six (6) one-hour sessions with a counselor. Each individual (single or married) has unique strengths and weaknesses, gifts and sin, and each problem is unique in its own way. Counseling and growth take time. The goal is that each counselee will, with their counselor, determine an appropriate time to end formal counseling sessions. Since your counselor is not licensed, they are not submitting directly to the ethics outlined by the Texas state board. However, they are submitting to God, the authority of the Bible, and the leadership of the local church to which they are covenanted. Therefore, any conduct by the counselor deemed inappropriate or sinful by God’s Word should be reported to one of the local pastors at Sojourn. Such behavior includes, but is not limited to: sexual innuendo, sexual contact, and inappropriate disclosure of personal information to others. If the conduct of your counselor is considered illegal by law, do not hesitate to contact the proper authorities. Content of your counseling sessions is confidential. However, legally and biblically, there are several conditions under which your counselor should break confidentiality. They are listed as follows: 1. If you threaten to hurt yourself or someone else. 2. If you disclose any involvement in child abuse or child pornography. 3. If your conduct merits church discipline as outlined in the by-laws of your covenant community. Should the counselee or counselor believe that a referral is needed, alternatives will be provided. A verbal exploration of alternatives to counseling will also be made available upon request. The counselee will be responsible for contacting and evaluating those referrals and alternatives.
Your Digital Signature *