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Renewal Group K - Calming Your Anxious Mind
All information is strictly confidential. The below questions will help the group counselor understand the needs of the group and of each participant. It will also allow the staff to discern if this group experience is a good fit with your counseling needs at this moment. Lastly, it allows potential participants to review and to commit to the policies for group membership and the guidelines for group meetings.
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Name:
*
Your answer
Date of Birth:
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Your answer
Phone Number:
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Your answer
Email Address:
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Your answer
Are you a NY or NJ resident? (Please indicate which)
Your answer
Marital Status:
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Single
Engaged
Married
Separated
Divorced
If you have children, please list how many and their ages:
Your answer
How did you hear about this Renewal Group?
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Your answer
Do you believe in God?
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Yes
No
What church do you currently attend?
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Write "None" if you do not currently attend one
Your answer
How much influence does your religion have on your day-to-day activity?
Your answer
What are your reasons for joining the Renewal Group?
What concerns have led you to be interested in this Renewal Group?
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Please include how long you have had these concerns
Your answer
Please rate the severity of your present concerns on the following scale (Check one):
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Mild
Moderate
Severe
Totally incapacitating
What do you hope to get out of your group experience?
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Your answer
Do you have any previous support group or group counseling experience?
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If yes, please describe what kind, when and for how long. If no, write "None"
Your answer
What other sources of care and growth do you have?
Examples: Are you in a church small group? Are you receiving care from your church diaconate? Have you sought pastoral counsel regarding this group topic?
Your answer
Information about counseling experience and needs:
Note: this information is completely confidential and available only to the program director and group counselor.
Name of current counselor or therapist (at RCS or elsewhere):
Your answer
Contact information for current counselor:
Please give us the counselor's 1) phone number; and 2) email address
Your answer
Do you currently see a psychiatrist?
If you do, please give his your psychiatrist's name and contact info. If not, leave this blank.
Your answer
Do we have permission to contact your counselor and/or psychiatrist?
We would only make contact if we need feedback on whether this therapy group is a good fit for you right now.
Yes
No
Clear selection
Psychiatric medications currently taking, if any:
Your answer
Have you ever been hospitalized for psychiatric purposes?
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Yes
No
Have you attempted suicide in the last 12 months?
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Yes
No
Are you currently struggling with any chemical addictions?
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Yes
No
If "yes" to any of the last few questions, please give us some details on the circumstances:
Your answer
Are there any other counseling-related issues you want us to know about?
Your answer
Group member commitments
Individual Therapy Agreement:
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I understand that if recommended by the group therapist, I will also need to complete individual therapy while in the group.
Yes
No
Signature:
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Please type your name as signature confirmation of all the above commitments. Thank you!
Your answer
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