STRONGER AFTER

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STRONGER AFTER

INTAKE FORM

Your Privacy: We take your privacy seriously. This intake questionnaire will only be accessed by the Stronger After Coaching Supervisor in order to contact you. After you have been paired up with a coach, only your coach will look at your intake questionnaire. Your name, email address, or information will not be shared with any third parties.

DISCLAIMER: Stronger After is a form of coaching and is in no way to be considered or substituted for psychological counseling or any other type of therapy or medical advice.

* 1. In what areas did you experience coercive control? *

Group: Religious, Social, Recovery, Educational, Recreational, Commercial, Political, etc.

Romantic Relationship

Family Relationship

Friend

Work

Therapy, Coach, etc.

Other:

Required

How did you become involved in the group or relationship? *

I was born into it

My parent(s) joined when I was a child or teenager

I became involved as a minor, but on my own

I became involved as an adult

Other:

I am still in the group / relationship / situation

I am going back and forth at the moment

I have left

If you answered " I have left," please specify how long ago:

How did you leave? *

I left on my own

Someone else left and I followed

I was forced to leave by the group

I am still in

Which types of abuse would you say you have experienced while in this situation? (Check all that apply) *

verbal

emotional

physical

neglect (medical / physical / ...)

sexual abuse as a child

sexual abuse or assault as an adult

mind games / gas-lighting

spiritual / religious

financial

domestic violence

none that I am aware of

Other:

Required

How often are you bothered by the following experiences? (Check each column as it applies) *

never

sometimes

often

always

not sure what the question means

Thoughts keep circling in my head. I can't make them stop.

I don't think I am worthy of love

I have nightmares

I have fears about the world ending, hell, karma or other punishment

I fear making mistakes

I feel shame for having participated

I experience difficulty making decisions

I feel a sense of dread

I experience anxiety and panic

I feel guilt for leaving the situation

I feel guilty for leaving people behind

I feel guilty for living / enjoying life

I have an internal voice that criticizes me or polices me

I feel alone / miss my community

I have strong beliefs and inner convictions that I didn't choose

I feel responsible for others and their needs

I lack boundaries and don't feel sure when someone is violating mine

I have difficulty connecting with other people

I have difficulty with sexuality and physical closeness

I have difficulty trusting others

I have difficulty finding a job or being able to keep it

I have issues with authority in the workplace or elsewhere

I have difficulty speaking up and not letting others take advantage of me

I have suicidal thoughts

I sometimes hurt myself

I feel exhausted

I feel stress from family who are still in the group or situation

I have no sense of who I am, my identity outside the group or situation

I feel powerless, that I have no control

Sometimes I get triggered and have flashbacks (feeling stuck in a memory)

I am afraid someone will come after me. I feel watched.

I have difficulty talking about what happened or making sense of my experience

I feel depressed and find it difficult to function

I feel very angry. There is so much rage inside.

I have a hard time connecting to my emotions

I feel a sense of grief and loss

I question my reasoning, how I make decisions

I feel compelled to do certain things and find it hard to stop myself

I put myself down

I miss feeling chosen or special

It's all or nothing - I don't seem to find the middle ground

I feel like I have no future without them

I still think in us-versus-them terms, who is the enemy now?

I look for absolute truth and instant solutions to my troubles

I cannot let go of people, even when they hurt me or are toxic

I daydream or just drift off, disconnect from my feelings or where I am

I cannot feel my body

I feel overwhelmed by my emotions, like I am drowning

I feel like I have to be productive all the time, have difficulty relaxing

I flinch when someone is loud or yells

I don't feel safe

I feel stuck because I was not allowed to continue my education

never

sometimes

often

always

not sure what the question means

Thoughts keep circling in my head. I can't make them stop.

I don't think I am worthy of love

I have nightmares

I have fears about the world ending, hell, karma or other punishment

I fear making mistakes

I feel shame for having participated

I experience difficulty making decisions

I feel a sense of dread

I experience anxiety and panic

I feel guilt for leaving the situation

I feel guilty for leaving people behind

I feel guilty for living / enjoying life

I have an internal voice that criticizes me or polices me

I feel alone / miss my community

I have strong beliefs and inner convictions that I didn't choose

I feel responsible for others and their needs

I lack boundaries and don't feel sure when someone is violating mine

I have difficulty connecting with other people

I have difficulty with sexuality and physical closeness

I have difficulty trusting others

I have difficulty finding a job or being able to keep it

I have issues with authority in the workplace or elsewhere

I have difficulty speaking up and not letting others take advantage of me

I have suicidal thoughts

I sometimes hurt myself

I feel exhausted

I feel stress from family who are still in the group or situation

I have no sense of who I am, my identity outside the group or situation

I feel powerless, that I have no control

Sometimes I get triggered and have flashbacks (feeling stuck in a memory)

I am afraid someone will come after me. I feel watched.

I have difficulty talking about what happened or making sense of my experience

I feel depressed and find it difficult to function

I feel very angry. There is so much rage inside.

I have a hard time connecting to my emotions

I feel a sense of grief and loss

I question my reasoning, how I make decisions

I feel compelled to do certain things and find it hard to stop myself

I put myself down

I miss feeling chosen or special

It's all or nothing - I don't seem to find the middle ground

I feel like I have no future without them

I still think in us-versus-them terms, who is the enemy now?

I look for absolute truth and instant solutions to my troubles

I cannot let go of people, even when they hurt me or are toxic

I daydream or just drift off, disconnect from my feelings or where I am

I cannot feel my body

I feel overwhelmed by my emotions, like I am drowning

I feel like I have to be productive all the time, have difficulty relaxing

I flinch when someone is loud or yells

I don't feel safe

I feel stuck because I was not allowed to continue my education

Which one of the following areas where influenced by the rules of the group or relationship? (Check all that apply) *

Behavior

Diet

Finances

Health Care

Information

Pets

Emotions

Education

Thoughts

Reading

Sexuality / Birth Control

Entertainment

Sexual Identity

Partner Choice

Work

Parenting

Free Time

Vacation

Creativity/Hobbies

No Rules

Other:

Required

In what ways do you feel like you were manipulated in the group or by an individual? (Check all that apply) *

Fears

Guilt

Mind-games/gaslighting

Dependency

Promises

Threats

Punishment

Sense of responsibility

Through family / children

Isolation

Lack of sleep

Lack of privacy

Lack of outside resources

Financial dependency

Housing

Not at all

Required

Are any of these currently impacting your life? (Check all that apply) *

Homelessness

Financial difficulty

Mental Health problems

Lack of education

Lack of Employment

Physical Health problems

No Identification documents

Lack of support system

Parental alienation

Difficulty finding a therapist

Not at all

Required

If you were in a group what kind of group was it? (Check all that apply) *

Christian

Judaic

Islamic

Therapeutic

Alternative Medicine

New Age

Eastern

Political

Multi-marketing

Personal development/Psychological

Conspiracy

Satanic

White Supremacy

Sex trade

Human Trafficking

Sports

School/Educational

Addiction/Recovery/Detention

Other:

Required

If you are comfortable, share a few sentences about what you experienced and how it has affected you.

I recognize Stronger After is a form of coaching and is in no way to be construed or substituted as psychological counseling or any other type of therapy or medical advice. *

Yes

Required

Email *

Please re-enter your email *

Thank you! We will reach out to you within 1-2 weeks. If you do not hear from us, please do not hesitate to contact us at coaching.stronger.after@gmail.com.

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