Mending The Soul: Intake Form

Your name (required)

Your email (required)

Your address (required)

Your phone number (required)

Gender (required)

Which class would you like to sign up for? (Class occurs weekly for 8-12 weeks)

Do you need childcare?

Please provide name and age.

Current marital status (required)

Number of years married (if applicable)

Does your spouse know you want to participate in a group? (required)

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)

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)

Please describe.

Are you at a time of great stress or important transition in your life? (required)

Please explain.

Would you consider yourself to be depressed? (required)

Please explain.

Have you ever had any serious thoughts about committing suicide or made a suicide plan or attempt? (required)

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)

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)

Please Explain.

Have you ever received professional, pastoral, or lay counseling? (required)

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)

What church?