Educational Support Group Intake Form-Virtual Classes
Mobile Phone Number
-
Area Code
Phone Number
Gender
Female
Male
LGBT
Other
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Race
African American
Hispanic
Caucasian/White
Asian American
Middle Eastern
Multi Race
Request not to answer
Other
Date of Birth
-
Month
-
Day
Year
Date
Educational Level
Below 6th grade
6-12th grade
High School Graduate
1-4 College/Tech
College Graduate
Post Graduate
Unknown
Other
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Disabilities
None
Cognitive
Deaf/Hard of Hearing
Developmental
Emotional/Psychological
Mental
Physical
Vision Impaired
Other
Employment
Emploed
Unemployed
Other
Type of Support Group
Sisters of Faith-Conference Call(First Saturday of Every Month at (10:00am)
SOS -Safe Online Space (Third Monday of Every Month at 5:00 pm)
LEAH- Domestic Violence - In House group (Weekly- call for dates)
RESTORE - Sexual Assault - In House Group (Bi-Monthly - Call for dates)
M.A.S.H. - Men Against Spousal Harm Group
Other
Referral Details (Who referred you and why)
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Is there an active Protection Order in place?
Yes
No
Other
Type of Abuse (Check all that apply)
Primary - Domestic Violence
Primary - Sexual Assault
Adult Sexually Abuse/Assaulted as a Child
Bully (Verbal, Cyber, or Physical)
Child Physical Abuse or Neglect
Child Pornography
Child Sexual Abuse/Assault
Domestic and /or Family Violence
Elder Abuse or Neglect
Hate Crime - Racial/Religious/Gender/Sexual
Human Trafficking - Labor
Human Trafficking - Sexual
Stalking/Harassment
Survivor of Homicide Victim
Teen Dating Victimization
Witness abuse (domestic or sexual) as a child
Witness or participate of interpersonal violence trauma
Other
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We'd like your input in planning our upcoming sessions so that they can best meet your needs.
Type a question
Very uninterested
Somewhat uninterested
Neurtal
Somewhat interested
Very interested
Healing for trauma
Releasing my past
Moving Forward
What other topics would you like to see as the focus for futur events?
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Do you consent to the following: (By checking off the answers below is form of your online signature?
To keep all information pertaining to group confidentiality
To keep your group leader informed of absences prior o session
To attend all group session as being a part of a recovery team
To understanding thath Our House, Inc. can not release any information about groupsessions without your written permission
To staff follow up with you if you Disclose of current incidents of interpersonal violence.
To agree to our Notice of Privacy Practices - 0n our Website Page (www.ourhousesvoices.com)
Other
Please verify that you are human
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Initials
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