Intake Forms

Our intake forms are provided here for you to fill out and bring to your first appointment along with a photo ID and insurance card.
Click on the link to download the Word document to your computer. 


​Adult Forms 

Includes the following forms:
- Fact Sheet
- Client History
- Consent to Use and Disclose Your Health Information
- Privacy Practices
- Financial Policy


​Minor Forms

Includes the following forms:
- Fact Sheet
- Client History
- Consent to Use and Disclose Your Health Information
- Privacy Practices
- Financial Policy
Sojourners Counseling Services, LLC
​111 South Mulberry St. Mount Vernon, OH | 740-393-6001 | [email protected]