Confessional Community Intensive Application Form

New Story Behavioral Health

6400 Arlington Blvd, Suite 920

Falls Church, VA 22042

events@newstorybh.com
The Confessional Community Intensive Application Form
Personal Information
Please be aware that communicating personal information electronically poses a risk to your confidentiality. New Story Staff will not disclose any personal information provided on this application form.
Full Name

First NameLast Name
Gender
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
E-mail
example@example.com
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Application Information
Please state how you learned about this event including any prior connection to New Story Behavioral Health.
Are you a mental health clinician? If so, what is your credential and practice setting?
Please indicate if you are experiencing any of the following:

AnxietyPersistent feelings of sadnessSelf-harmPanic attacksBingeing or purging foodSuicidal IdeationLonelinessOvereatingSleep problemsChronic painDomestic violenceAlcohol abuseObsessive thoughtsPrescription drug abuseIllicit drug abuseLegal problemsPhobiasCompulsive behaviorsSocial isolationImpulsive behaviorUnresolved griefNeighborhood violenceFinancial problemsMarital problemsParenting problemsRelationship problemsJob-related problemsFaith-related problemsGambling addictionSexual addictionAngry outburstsViolent thoughts or behaviorDiscrimination
Please be prepared to provide additional information about any of the above issues to your screener.
Please list any medical or mental health diagnoses:
Please list any medications and their purpose:
Are you currently receiving mental health treatment? If so, what type and frequency?
What previous experiences have you had sharing intimately in a small group context? When? For what duration? What type of group? Were you a leader, participant, or both?
Have you been hospitalized for psychiatric care? If so, when and for how long? What was the presenting problem? What were the resulting diagnoses?
As a result of participation in this event, participants may experience distress related to greater awareness of the impact of events or circumstances on their psychological well-being. Each participant must identify a mental health or pastoral care professional who is available to provide support after this event should the participant need it. New Story staff can provide referrals for support within the Washington, DC metropolitan area. Participants from outside the DC area should find resources before attending the event.
Name of mental health or pastoral care resource:
Do you know others who plan to attend this event? Please provide names and relationship to you:
Please note that we try to avoid placing participants who have a pre-existing relationship in the same confessional community. Discuss any concerns with a New Story staff member.
Are you interested in receiving training to lead your own Confessional Community? Please note that the Confessional Community Intensive is not a comprehensive training event.
What questions or concerns do you have prior to participating in this event?
Disclaimers and Notices:

The Confessional Community Intensive, provided by New Story Behavioral Health (“New Story”), isconsultative in nature and does not constitute mental health treatment. Participants should not consider participation in this event as a substitute for mental health treatment. Participants in need of mental health referrals or treatment should contact New Story staff to request assistance. The Confessional Community Intensive is not a training event. Though some experiential and didactic learning will take place, the Intensive does not provide comprehensive training for individuals who wish to conduct similar groups.

Participants in events and services provided by New Story understand that conversations and interactions in the context of interpersonal groups may, at times, produce emotional discomfort (e.g. anxiety). Participants acknowledge and accept this risk and are reasonably confident in their ability to tolerate emotional discomfort. Participants agree to discuss any mental health concerns with a staff member before participating in events or services provided by New Story. Mental health concerns that warrant discussion include but are not limited to: active addictions; psychotic episodes; panic attacks; or persistent emotional dysregulation. New Story staff members may at any time suspend a participant’s participation in an event if there are concerns about the participant’s or other participants’ safety or well-being.

Participants agree to maintain strict confidentiality both during and after the Intensive. Confidentiality includes not disclosing other participants’ identifying information or personal content shared by other participants.

Participants may not reproduce any written or digital material obtained from New Story without written permission.

Participation in this event is by application only. Applicants must complete this application form and participate in a screening appointment with a New Story staff member. Acceptance of participation in this event is not guaranteed regardless of an applicant’s previous experience with New Story. Acceptance of participation in this event does not guarantee acceptance as a patient at New Story or imply that accepted participants will be able to receive mental health treatment at New Story after the event. Acceptance of participation in this event does not guarantee acceptance to subsequent events at New Story.

Thank you for completing this application. A New Story staff member will contact you to inform you of next steps.
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The Confessional Community Intensive Application Form

Personal Information

Application Information