Pre-Group Questionnaire
Kindly fill out the questions below if you are interested in applying for my Women's Support Group. 
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Client Information
Date *
Name
 *
Age and Date of Birth
 *
Occupation
 *
Employer/School
 *
Marital Status
 *
Do you have children?
 *
If yes, names & ages
Who lives in your home? *
Home Address *
What is your primary phone number, and is it ok to leave messages? *
What is your secondary phone number, and is it ok to leave messages? *
Email Address *
Have you ever seen a mental health professional (psychiatrist, psychologist, marriage and family therapist, social worker, counselor)? *
Required
If yes, when? Please briefly list the reasons.
Do you have a therapist you could work with if something came up in the group requiring individual attention? *
If not, would you like referrals to therapists? *
Are you currently taking any medication for mental health issues? *
Required
Any other medications? If yes, please explain:
Are you in recovery from substance or alcohol abuse? If so, how long have you been sober? Please provide a brief description of the treatment and support you
receive for maintaining sobriety. *
Have you experienced distressing life events (trauma, loss, etc.) that have significantly impacted your functioning and quality of life? If so, please provide information about how you have addressed these issues. *
What sparked your interest in attending the group? *
What would you like to accomplish as a result of attending the group? *
What previous experience have you had, if any, with group therapy or a support group? Please list dates and the name of the group. *
What worked well for you? *
What difficulties did you have, if any? *
What concerns, if any, do you have about participating in a therapy group? *
How would you respond as a group member if someone in the group dominated the discussion? *
How would you respond as a group member if someone never participated in the group discussion? *
What else would you like us to know about you? *
Please review the group topics below and indicate your order of preference (number 1-7):
What is impacting my sense of self-worth? *
Why didn't I complete my education/training? *
Why do I continue to take on added responsibiities? *
Why did I choose my mate? Is my relationship what I want it to be? *
Are my financial decisions well thought out or do I act impulsively with my finances? *
Why do I continue to feel responsible for my adult children/siblings? *
Am I behaving in a way that is consistent with my values, goals and spiritual beliefs? *
What is the best way to follow up with you? *
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