Group & Workshop Form
This is the intake form for our Groups and Workshops program facilitated by the Sexual Assault Support Centre of Waterloo Region. This form is meant to be completed before starting the program so that the program facilitators can best support you during the group/workshop. There are no wrong answers to these questions and all of your answers will be confidential. You can skip any questions you don't want to answer. If you have any questions or concerns, please email Adria Joel, the Group and Workshop Coordinator at groups@sascwr.org. If you are struggling, please reach out to our 24-Hour Support Line at 519.741.8633
University of Waterloo Online Groups (Please choose one or more that you'd like to register for)
Healing from Sexual Violence - 6-week Closed Group: Wednesdays, 7:30 - 9:00 PM (February 1 - March 15)
Healing from Sexual Violence - 8-week Closed Group: Tuesdays. 1:00 - 2:30 PM (January 24 - March 21)
Still I Rise (for Black women, non-binary and gender non-conforming survivors): Third Monday of every Month from 3 - 4:30 PM (starting December 19)
Name
*
First Name
Last Name
Email
*
example@example.com
Please select the one that applies:
I have already filled out the One on One Counselling intake form
I have already filled out a Group & Workshop Intake form
I have already filled out both of the above forms
I have not filled out either of the above intake forms
What are your preferred pronouns?
She/Her
He/Him
They/Them
Other
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Is it safe to leave a message?
Yes
No
Is there a different name you would like to use in group with other participants? If so, please provide that name here.
Note:
As an intersectional, feminist organization, we want to ensure that we are providing services to those who reflect our community. These three sections below will help us to capture our demographics. If you feel comfortable, please check all those that apply (optional).
Please select those that apply to you and how you identify.
Black: African, Afro-Caribbean,Caribbean-Canadian, African Canadian descent
East Asian: Chinese, Korean, Japanese, Taiwanese descent
Indigenous: First Nations, Métis, Inuk/Inuit descent
Latino/Latinx: Latin American, Hispanic descent
Middle Eastern: Arab, Persian, West Asian descent (e.g. Afghan, Egyptian, Iranian, Lebanese, Turkish, Kurdish)
South Asian: South Asian descent (e.g. East Indian, Pakistani, Bangladeshi, Sri Lankan, Indo-Caribbean)
Southeast Asian: Filipino Vietnamese, Cambodian, Thai, Indonesian, other Southeast Asian descent
White: European descent
Other
Please select those that apply to you and how you identify.
Cis Female
Trans Female
Cis Male
Trans Male
Two Spirit
Non-Binary
Gender Fluid
Agender
Other
Do you identify as part of the 2SLGBTQIA+ community?
Yes
No
Other
Are you a University of Waterloo student?
Yes
No
Other
Are you currently attending counselling?
No
Yes
If yes, where are you attending counselling?
Do you have any previous group or counselling experience?
No
Yes
What was helpful for you in your past group or counselling experience(s)?
If you were feeling anxious/triggered/alarmed, would you feel safe bringing it to the facilitator’s attention?
Yes
No
Unsure
If you become activated, what would you do to take care of yourself in the moment? How can facilitators support you in these moments?
What is your learning style pertaining to a group situation?
Visual
Auditory/Listening
Discussion
Activities/Hands-on
Other
Are you comfortable sharing in groups? Any fears? (Note that we will not put you on the spot and there is no obligation to share. We also do not go into specifics of trauma in a group setting).
Who is your support network? (for example, friends, family, community supports)
Any accommodations needed for accessibility?
Do you have any food allergies or other health issues that might affect you in group the facilitators should know about?
No
Yes
What are they?
Do you have any questions or concerns to share with us? Anything else that would be important for us to know?
Do you prefer groups in person or virtual?
In person
Virtual
No preference
Other
Would like to be added to the group and workshop contact list to receive emails about new upcoming groups and workshops?
Yes
No
If you are interested in other group offerings through SASC, visit sascwr.org/groups.
Submit
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