Group Therapy Intake Form

For residents of Indiana, Florida and South Carolina ONLY at this time.

Full Name

Today's Date

Best Name/Preferred Name

Date of Birth

Email address

Street Address

City

State/Province

Zip Code

Country

County in your State

Gender

Please attach a copy of your Drivers License or State ID and a copy of your therapist's business card (if you have not sent this already).

Add file

Please upload a file

Are you currently in individual therapy?

Yes No

If you are in therapy, has your therapist approved your participation in our therapy group?

Group Therapy requires a letter from your therapist, but acceptable from your psychiatrist or family physician. Have you requested this letter be emailed or faxed to us?

Yes No Yes, but I need an encrypted link to give to them..

Which group therapy are you wanting to join?

Domestic Violence Group Therapy - 10 Weeks

Tuesdays at 1 pm Eastern (10 am Pacific)

Eating Disorders & Trauma - 12 Weeks

Fridays at 7 pm Eastern (4 pm Pacific)

Women's Group Therapy - 12 Weeks

Wednesdays at 8 pm Eastern (5 pm Pacific)

Are you currently living with someone who is abusive?

Yes

I'm not sure

Do you have a faith or spiritual belief that helps you cope with your recovery after your abuse/sexual trauma.

Other issues in the last 30 days

What kind of abuse or sexual trauma have you experienced in your lifetime (Check all that apply)?

Domestic Abuse

Emotional Abuse

Neglect

Physical Abuse

Rape/Sexual Assault

Sexual Abuse

Sex Trafficking

Spiritual/Religious Abuse

Below is a list of problems that people sometimes have in response to a very stressful experience. Please reach each problem carefully and then rate how much you have been bothered by that problem in the past month.

Please rate each according to how bothered you have been during this time.

0 = Not at all

1 = A little bit/Once a week

2 = Moderately/2-3 times a week

3 = Quite a bit- 4-5 times a week

4 = Extremely/ 6-7 times a week

1. Repeated, disturbing, and unwanted memories of the stressful experience?

2. Repeated, disturbing dreams of the stressful experience?

3. Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?

4. Feeling very upset when something reminded you of the stressful experience

5. Having strong physical reactions when something reminded you of the stressful experience (for example, people, places, conversations, activities, objects, or situations)?

6. Avoiding memories, thoughts, or feelings related to the stressful experience?

7. Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)?

8. Trouble remembering important parts of the stressful experience?

9. Having strong negative beliefs about yourself, other people, or the world (for example, having thoughts such as: I am bad, there is something seriously wrong with me, no one can be trusted, the world is completely dangerous)?

10. Blaming yourself or someone else for the stressful experience or what happened after it?

11. Having strong negative feelings such as fear, horror, anger, guilt or shame?

12. Loss of interest in activities that you used to enjoy?

13. Feeling distant or cut off from other people?

14. Trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?

15. Irritable behavior, angry outbursts, or acting aggressively?

16. Taking too many risks or doing things that could cause you harm?

17. Being "superalert" or watchful or on guard?

18. Feeling jumpy or easily startled?

19. Having difficulty concentrating?

20. Trouble falling or staying asleep?

Please provide a list of the children currently in your care or that you are responsible for, with their gender and ages.

What made you decide that group therapy would be beneficial at this time?

What are the goals you would like to achieve if accepted into this group?

Any other information you would like to share?

What is your monthly or weekly income? Please specify if it is monthly or weekly.

How many people are you financially responsible (yourself, spouse, and how many minor children)?