Support Group Form

Instructions:

Request must be submitted by the client.

Hi,

Thanks for your interest in the Intensive Social Anxiety Group. We're over the moon about this group, and we look forward to learning more about you!

Creating a supportive group dynamic is an art. We put a lot of thought into creating a supportive, dynamic group. Let's determine if the group is the right fit for you.

Your name

Email address

Phone number

Age & Date of Birth (00/00/00)

Why are you interested in the group?

The group isn't appropriate for everyone. Individual counseling is often a better fit. Please check if you're impacted by any of the following: Please read carefully. Release from the group is likely if any of the following are impacting you or group progression. Thank you!

I am struggling with suicidal thoughts, or engaging in self-harming behaviors.

I have been diagnosed with a bipolar condition, or another mood condition that impacts my ability to keep a schedule and maintain consistent energy levels.

I have been diagnosed with a personality condition, or I often find it difficult to sustain a peaceful balance of power in my relationships.

I am currently using substances (alcohol/drugs) on a regular basis, impacting the following day (hungover/sick) at least 1x monthly.

I am not struggling with any of the above.

The group will address cognitive-emotional-behavioral aspects related to social anxiety. Are you open to exploring new behaviors and supporting others wanting to develop new cognitive-emotional-behavioral patterns? Please explain.

Social anxiety is sooo consuming. Of all the symptoms, which one do you dislike the most? How does it impact you?

If social anxiety was no longer an issue, how would your life be different? What would you do differently?

Currently, how do you manage your anxiety symptoms? Meaning- how do you modify your environment, or stress triggers to decrease anxiousness?

In the last three months, can you find 1 accomplishment which brings you pride or joy? Can be anything (related or unrelated to anxiety). Big or small.

Thank you! This is so helpful. Lastly, do you consent to sending this HIPAA-complaint digital form?

Yes, I consent.

Your information will be encrypted.

Support Group Form

Instructions:

Instructions:

Conscious Counseling & Education Center