Intensive Support Programming

Full Name

Today's Date

Best Name/Preferred Name

Phone Number

Date of Birth

Email address

Street Address

City

State/Province

Zip Code

Country

County of Your State of Residence

Gender

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

Add file

Please upload a file

Which Intensive Support Program are you completing this intake form for?

Eating DIsorder & Trauma (includes PTSD) Trauma Recovery (PTSD & Dissociation)

Are you currently in therapy?

Yes No

If you are in therapy, have you spoken with your therapist about joining our Trauma Recovery Intensive Support Program, and is he/she supportive of this?

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 (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, with their names and ages. Please share if your symptoms are impacting them.

What made you decide that an intensive support program would be beneficial at this time?

What are the goals you have for yourself for this program?

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)?

Questions for the Eating Disorder & Trauma Intensive Support Program Only

All questions in this section is required for our EDTISP program.

Please tell us about your eating disorder, including how old you were when it started, what your symptoms you are experiencing, and what are the most significant behaviors you have with your eating disorder.

When is the last time you saw a physician who took blood work for your eating disorder, and what were the results of your bloodwork? If you have not spoken with your physician about your eating disorder, do you have any plans to do so, or do you have another physician that you work with for your bloodwork for your eating disorder?

When is the last time you saw your therapist? Are you working on both the trauma and your eating disorder? If not, what is your primary focus in treatment?

Have you ever been hospitalized for your eating disorder or trauma? If so, when was the last time and what was the reason you were hospitalized?

Have you ever been in residential treatment for your eating disorder and trauma? If so, please provide us with when and more information about that admission.

If you live in Florida, Indiana or South Carolina, are you interested in group therapy with your program? This is only an option if you live in these 3 states at this time.

Yes No

Schedule:

Group sessions three days per week for 2 hours a day for 8 to 12 weeks which is established at your intake.

Cost:

$10 per session for support sessions.

$25 per session for group therapy sessions.

We do not accept insurance.

A sliding scale or alternative payment plan is available.

Cameras & Attendance:

Attendance in this program is with your camera on, participating in a quiet space where you are sitting down. You may not be driving around or walking around in your home during groups. If you need to cancel a group, please notify your group facilitator by replying to the email you receive with your login.

You will receive an email from us which will be encrypted. The first email you will need to set a passphrase that you will use for your future emails from us.

I wish to meet with someone to join one of the intensive Support Programs. I've attached my Picture ID above.

Your information will be encrypted.

Intensive Support Programming

Questions for the Eating Disorder & Trauma Intensive Support Program Only

Hope Recovery