JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Group Questionnaire
This following questions will help determine readiness of potential group members. Please answer questions completely.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Name:
*
Your answer
DOB:
*
MM
/
DD
/
YYYY
Please list your Race/ Ethnicity
*
Your answer
Gender (How You Identify)
*
Female
Male
Prefer not to say
Other:
Phone Number
*
Your answer
Address
*
Your answer
Are you a Florida resident (Do you live in Florida)?
*
Yes
No
Are you currently receiving therapy services? If Yes, select service you are receiving.
Choose
Individual Therapy
Family Therapy
Couples Therapy
Group therapy
Other
None of the above
Have you attended group therapy before? If so give date
Your answer
What would you like to get out of this group or learn?
*
Your answer
What 3 words best describe your personality?
Your answer
Are you currently on any medication(s)? If yes, list
Your answer
How would you describe you current physical health good, fair, or poor?
Your answer
How would you describe your current mental/emotional health good, fair, or poor?
Your answer
Are You Suicidal? National Suicide Prevention Helpline (Available 24/7) 1-800-273-8255.
*
Choose
No
Yes, Thoughts only
Yes, Thoughts and plan
Yes, Attempt(s)
Suicidal? If yes, please explain?
Your answer
Are you able to attend group meetings Thursday Evenings?
*
Yes
No
List any group preferences that you have (gender, age, group size etc.).
Your answer
How did you find us?
T4BG
Google search
Referral
Website
Instagram/FB
BHenson
DRK Beauty Healing
Other/Unknown
Clear selection
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
