Narcissistic Abuse Recovery Group Intake Form

Today's Date

First Name

Last Name

State

Preferred Email

Time Zone

Phone Number

Telephone Number For Emergency Services in Your Area

Emergency Contact Name /Relationship to You

Emergency Contact Number

Date of Birth

Age

Gender

Address

City/State/Zip

Country

Are you currently seeing a mental health professional or coach?

Yes

No

Name of Practitioner

Practitioner Phone Number

Are you currently taking any medications?

Yes

No

List all medications/dosages including, herbal supplements, non-prescription medications, and substances

Are you having any of the following symptoms? Check all that apply.

Sleeping too much

Insomnia

Sleeping Too Much

Ruminations/Obsessive Thoughts

Anxiety

Mood Changes

Anger

Crying Spells

Feeling Detached/ Disassociated

Emotional Flashbacks

Thoughts of Harm to Self or Others

Focus/Concentration/ Memory Issues

Social Isolation

Nightmares

Cognitive Dissonance

In the past month, have you had thoughts of suicide?

Yes

No

Have you ever had a psychiatric hospitalization and/or suicide attempt(s)?

Yes

No

If yes, please explain. Include dates/ treatment/ precipitating event, etc...

Do you have chronic pain or any medical conditions?

Yes

No

If yes, please explain.

How often do you drink alcohol?

Never

1 to 2 times per week

Daily

A couple times a month

I think about cutting back on my drinking often.

I had a problem in the past, but I'm in recovery now.

Are you employed?

Yes

No

If yes, what do you do for work?

What do you hope to get out of the group? What are your goals?

Narcissistic Abuse Recovery Group Intake Form

Bree Bonchay, LCSW

Are you having any of the following symptoms? Check all that apply.

Bree Bonchay, LCSW