Finding You Therapy Programs - Intensives Application

Background Information:

Your answers to these questions help us get to know you and better address your needs and expectations. Finding You Intensives does not purport to treat or diagnose mental illness. Answering yes to the following questions does not automatically preclude you from participation, but it does indicate the need for additional follow-up to determine whether we can provide an adequate level of support. We appreciate your candid response in advance.
What led to your decision to attend an Intensive?*
What do you hope to gain by participating in this program?*
What issues or concerns are you wanting to address in the Intensive?*
What do you experience currently as major obstacles/challenges?*

Please describe current relationships and dynamics in your family:*
Please describe previous treatment/therapy experience:*
Have you or any immediate family members demonstrated violence towards self or others? (examples: self-harm, property damage, physical altercations). If yes, please describe the situation, specific behaviors, and date(s):*
Have you or any immediate family members attempted or thought about suicide? If yes, please describe the situation, dates, and current safety/support plan:*

Have you or any immediate family members experienced a psychotic episode or received a diagnosis of schizophrenia or schizoaffective disorder? If yes, please describe the date and circumstances of most recent episode, and current approach for symptom management: *
Please describe any history of diagnosed disorder and treatment for yourself or immediate family members (depression, anxiety, eating, behavioral, etc.):*
Have you or any individuals in your immediate family experienced any traumatic events or loss? (abuse, divorce, bullying, sudden death of a loved one, injury/illness, etc.)? Please explain: *
Have you/do you experience dissociation or panic? If yes, please describe what helps you self-regulate:*
Please describe any addictive or self-medicating behaviors that you are currently experiencing, if any: *

Participant Medical Information:

In order to provide you with the best support, please complete as much of the personal information below as possible. Intensives may also include outdoor experiences, short hikes, or interactive activities.
Do you have any known allergies?*

YesNo
If yes, please list known allergies (medicines, foods, insect bites/stings, etc.); include the severity of reaction, specific details of last occurrence, date, how was the incident controlled?