Healthy Relationship Educational Support Group / DV Curriculum Group Intake Form

Healthy Relationship Educational Support Group / DV Curriculum Group

Intake Form

Welcome to TeeJuh Behavioral Health, where we believe in the transformative power of mindfulness and support. Our mission is to guide and inspire individuals on their journey to inner peace, tranquility, and conscious living. By offering a wealth of resources, tools, and practices, we aim to empower you to cultivate a more mindful, balanced, and fulfilling life.

At TeeJuh, we understand the challenges of modern living and the constant distractions that can pull us away from the present moment. Through our expertise and advocacy practices, we are committed to helping you navigate the complexities of daily life with grace and composure. We invite you to join our vibrant community of individuals who are committed to embracing and deepening their connection to the present moment. By exploring our diverse range of resources, including guided meditations, mindful exercises, and insightful articles, you can embark on a transformative journey towards greater self-awareness and emotional well-being.

This intake form provides a foundation for understanding the client's background, current challenges, and support network, while also addressing important logistical and legal considerations.

This intake form is designed to gather essential information about the participant's interest in the topic, availability, and expectations for the support group. It provides a foundation for organizing and customizing the support group to cater to the specific needs and preferences of the participants.
Does the time for your group work with your availability?
1. Name
2. Age
3. Gender
4. Preferred Pronouns
5. Contact Email
example@example.com
6. Phone Number
7. Address
8. Are you Alaska Native or American Indian?
9. What Village or Tribe?
10. How did you hear about this support group?

Initial Information
What are your main reasons for participating in group at this time?

Support, Coping & Strengths
Describe your current living situation and support network.
Do you have any notable sources of stress in your life such as work, relationships, or other factors?
Are you currently engaging in any regular physical activity, hobbies, or stress-reducing activities?
What are your strengths, or the things you feel you are good at?

Mental Health
Have you received behavioral health services or counseling in the past or currently? Was this for yourself and/or with another person? If so, please provide details.
Please list any symptoms or issues you have been experiencing, including but not limited to anxiety, depression, stress, trauma, or any other concerns.
Are there any specific coping strategies or support systems that have been helpful for you in the past?
Are you currently taking any medication for behavioral health conditions? If yes, please specify.

Physical Health
Do you have any known medical conditions? If yes, please describe.
Are there any other healthcare professionals or specialists involved in your care? If yes, please provide their contact information.

Relationship Health
What are your primary areas of concern related to your relationships?
Please describe any specific challenges you are facing in your relationships or interpersonal interactions.
Are you currently in a romantic relationship, and if so, how would you characterize its health and dynamics?
Are there any past experiences or traumas that may be specifically impacting your current relationships?
Have you previously sought counseling or therapy for relationship-related issues? If so, please provide details.

History
Briefly describe your childhood and upbringing, including any significant events or experiences that may have had an impact on your life.

Goals
What are your primary goals for participating in this group?
Is there anything specific that you would like to learn about while participating in this group?
How do you envision improving your relationships through participation in this support group?
Are there any concerns or potential challenges related attending group services that may impact you meeting your goals?

Technology & Internet Access
Do you have reliable access to the internet and a computer or device with a camera and microphone?
Have you used Zoom or other video conferencing platforms before?
Are there any technical or accessibility considerations that the group facilitators should be aware of?
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Date Intake Form Completed

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