Name
*
First Name
Last Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
*
Phone
*
(###)
###
####
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone #
*
(###)
###
####
How did you hear about this group?
*
Have you ever seen a mental health professional (Psychiatrist, psychologist, marriage and family therapist, social worker, counselor?)
*
If yes, when? Please briefly list the reasons and outcomes.
*
Do you have a therapist you could work with if something came up in this group requiring individual attention?
*
Are you currently taking any medication for mental health issues?
*
If yes, when? Please briefly list the reasons and outcomes.
*
Are you in recovery from substances or behavioral addictions?
*
If yes, how long have you been in recovery? Please provide a brief description of the treatment and supports you have and are currently receiving.
*
Have you experienced distressing life events (trauma, loss, etc.) that have significantly impacted your functioning and quality of life? If so, please provide information about how you have addressed these issues.
*
What caused your interest in the group at this time?
*
What would you like to accomplish as a result of attending our group?
*
What previous experience have you had, if any, with group therapy or a support group? Which groups did you attend?
*
If you have attended a support group, what was helpful? If you had any issues, what were they?
*
What concerns, if any, do you have about participating in a group experience?
*
How would you respond as a group member if someone in the group dominated the discussion?
*
How would your respond as a group member if someone never participated in the group discussion?
*
What else would you like me to know about you?
*
