LEAH Educational Support Group Intake Form-Virtual Classes

1
Name
First Name
Middle Name
Last Name
2
Safe Phone Number
Area Code
Phone Number
3
Is this a mobile phone number?
YESNO
4
GENDER
Please Select
Please Select
Female
Male
LGBTQI+
5
RACE
Please Select
Please Select
African American
Hispanic
Caucasian/White
Asian American
Middle Eastern
Multi Race
Request not to answer
6
DATE OF BIRTH (optional)
Date
Month
Day
Year
7
EDUCATIONAL LEVEL
Please Select
Please Select
Below 6th grade
6-12th grade
High School Graduate
1-4 College/Tech
College Graduate
Post Graduate
Unknown
8
EDUCATIONAL LEVEL
Below 6th grade
6-12th grade
High School Graduate
1-4 College/Tech
College Graduate
Post Graduate
Unknown
Other
9
DISABILITIESCheck all that apply
Please Select
None
Cognitive
Deaf/Hard of Hearing
Developmental
Emotional/Psychological
Mental
Physical
Vision Impaired
10
EMPLOYMENT (optional)
Employed
Unemployed
Other
11
LEAH - LETTING EACH AFFLICTION HEALCheck the group you are interested in attending.
LEAH- Domestic Violence - On site Group (1st Thursday, 11:30 am to 1:30 pm)
LEAH - Domestic Violence - Virtual Group (2nd & 4th Thursdays each month, 6:30 pm to 8:30 pm)
Other
12
Referral Details (Who referred you and why)
13
IS THERE AN ACTIVE PROTECTION ORDER IN PLACE?
YESNO
14
TYPE OF ABUSE* This field is required.Check all that apply
Please Select
Primary - Domestic Violence
Primary - Sexual Assault
Adult Sexual 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
15
WHAT ARE YOU PRIMARILY INTERESTED IN
YesNo
YesNo
YesNo
Healing for trauma
Releasing my past
Moving Forward
Healing for trauma
YesNo
YesNo
YesNo
1 of 3
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Do you consent to the following: (Checking the boxes below serves as your online signature and consent to comply with the guidelines.)* This field is required.
To keep all information pertaining to group confidential
To keep your group leader informed of absences prior to the session
To attend all group sessions as being a part of a recovery team
To understand that Our House, Inc. cannot release any information about group sessions without your written permission unless it violates our confidentiality policy.
To disclose current incidents of interpersonal violence
Other
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Initials* This field is required.
Should be Empty: