Narcissistic Abuse Recovery Group Intake Form

Narcissistic Abuse Skills and Support Group Application

Hi! I’m so glad you're interested in joining the group. Each session is around 60 to 90 minutes and starts with a structured, course-like format. I’ll introduce a topic aimed at deepening your self-understanding and supporting your healing from the impact of narcissistic abuse. Through group discussions, I’ll guide everyone in applying these insights to themselves using verbal and written self-exploration exercises and assessments. We’ll finish with time for sharing questions, insights, challenges, and offering support.

Each group is limited to a maximum of 8 participants.
Sessions are held online via Zoom.
Please note: this is not a psychotherapy group and is not covered by insurance.

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

Sexual Preference

Address

City/State/Zip

Country

Are you currently seeing a mental health professional or coach?

Yes

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

Sleeping too much

Insomnia

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

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

Yes

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

Are you employed?

Yes

If yes, what do you do for work?

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

I understand that the group is not covered by insurance.

I understand that the cost to attend each group session is $50.00.

I agree to maintain confidentiality within the group, ensuring that anything shared remains within the group, respecting privacy, preserving anonymity, and fostering trust to create a safe and supportive environment for everyone.

Are you available to join the group on Tuesdays at 6 PM PST / 8 PM CST / 9 PM EST?

Yes

Are you available join the group on Sunday at 5 PM PST / 7 PM CST / 8 PM EST?

Yes

Are you available to join the group on Wednesdays at 6 PM PST / 8 PM CST / 9 PM EST?

Yes

Please list your preferred group times in order of priority. If none of the current times work for you, let us know the times you’re available, and we’ll consider opening a group if there’s enough interest.

If you have any questions, please email me at breelcsw@hushmail.com

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