Mending The Soul: Intake Form Your name (required) Your email (required) Your address (required) Your phone number (required) Current marital status (required) ---MarriedSingleDivorced Number of years married (if applicable) Does your spouse know you want to participate in a group? (required) ---YesNo Level of Education (required) Please briefly describe your story of pain or abuse and why you are interested in attending a small group for healing. (required) How would you describe your personal health? Do you have any health issues that may prevent you from attending group regularly? (required) Are you currently taking any prescription drugs? (required) ---YesNo Which ones and for what purpose? The effects of abuse sometimes lead to other struggles that we are not equipped to handle in depth during small group meetings. Are you struggling with any behaviors with which you may need some extra support outside of the group such as recreational drug or alcohol use, an eating disorder, workaholism, sexual addiction, internet addiction, spending addiction, or codependency? Are you already receiving support for any of these struggles? Please explain. (required) Are you currently in an abusive relationship? (required) ---YesNo Please describe. Are you at a time of great stress or important transition in your life? (required) ---YesNo Please explain. Would you consider yourself to be depressed? (required) ---YesNo Please explain. Have you ever had any serious thoughts about committing suicide or made a suicide plan or attempt? (required) ---YesNo Please describe. Have you been diagnosed with a mental illness, including Obsessive Compulsive Disorder (OCD) or Bi-Polar Disorder (BPD), also known as Manic Depressive Disorder? (required) ---YesNo How is it being treated? Do you see any reason why this condition would interfere with your ability to concentrate on the workbook material required for this group? Is there anything else in your life that may make it difficult for you to concentrate that we should be aware of? (Personal habits or mannerisms, ADD, ADHD, etc.) (required) ---YesNo Please Explain. Have you ever received professional, pastoral, or lay counseling? (required) ---ProfessionalPastoralLayNone List number of years, purpose, and approximate number of sessions. Describe your religious upbringing. Please note that the group is open to those from ALL religious backgrounds. (required) What is your perception of God? (required) Do you have a church home? (required) ---YesNo What church?