Women's MTS Intake Form

Name

Phone Number

Address

City

Zip Code

Marital Stutus

Please briefly describe your story of pain or abuse and why you are interested in attending a small group for healing

How would you describe your personal health? Do you have any health issues that may prevent you from attending group regularly?

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.

Are you currently in an abusive relationship?

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

Would you consider yourself to be depressed?

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

Have you been diagnosed with a mental illness, including Obsessive Compulsive Disorder (OCD) or Bi-Polar Disorder (BPD), also known as Manic Depressive Disorder?

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.)

Have you ever received professional, pastoral, or lay counseling?

Is Desert Breeze your church home?

Women's MTS Intake Form

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