Women's Empowerment Group Application

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THIS GROUP IS DESIGNED TO HELP YOU DEFINE YOURSELF OUTSIDE OF YOUR ROLES, STAND YOUR SACRED GROUND, ADVOCATE FOR YOURSELF AND OTHERS AND FIND YOUR UNIQUE VOICE WHILE CULTIVATING A COMMUNITY THAT EMPOWERS EVERY WOMAN.

Email *

DUE TO STATE REGULATIONS WE ARE UNABLE TO ACCEPT CLIENTS WHO ARE COVERED BY COLORADO MEDICAID PLANS.

FULL NAME *

AGE *

GENDER *

SEXUAL ORIENTATION *

RELATIONSHIP STATUS *

EMERGENCY CONTACT *

PHONE # *

What else would you like us to know about you? *

This group has limited space. Can you commit to 10 consecutive weeks?

Yes

Other:

Clear selection

Why do you feel that attending the group is important now?

How do you see yourself contributing to this group?

What goals will this group help you achieve?

How will you know if you are getting closer to achieving these goals?

What are some obstacles or challenges that may keep you from participating and achieving your goals?

Are there any situations in your current life that might get worse if you accomplish your therapy?

Who do you currently consider sources of support in your life?

Help us understand how you handle stress:

In my day to day life, when I have an upsetting situation:

I tend to fall apart and not be able to function for a day or more

I tend to pick myself up in a few hours, but continue to ruminate on it

I tend to get over it in less than an hour and get on with the day

I tend to deal with it in a positive way without letting it get to me

Other:

When I fall apart or get terribly upset:

I take some medications or tranquilizers

I take alcohol/dugs/to find some comfort

I seek out a friend to talk

I am able to deal with it without any kind of help

I shut down/get away/retreat/go to bed

Other:

What are your top three coping strategies?

In this group, we will be discussing relationships, boundaries, bodies, sexuality, and sexual health with an understanding that every woman views theses topics differently. Are there topics that you would feel uncomfortable discussing? If so, please help us understand your concerns:

A copy of your responses will be emailed to the address you provided.

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