Totality

Intake Form

For Complimentary Community Group Therapy
Intake Form for Complimentary Community Group Therapy

Purpose:

This intake form is designed exclusively for participation in the Complimentary Community Group Therapy for individuals impacted by the wildfires in Los Angeles. These sessions are offered via Telehealth and are limited to 15 participants per group.
Group Schedule:

- January 28, 2025, at 11:00 AM

- February 4, 2025, at 11:00 AM

- February 11, 2025, at 11:00 AM

- February 18, 2025, at 11:00 AM

- Location: Online (Telehealth) via Zoom

- Facilitators: PsyD. Brooke Adams & CADC II/Certified Grief & Loss Counselor Judy Shafer

Participant Information:
Name
Date of Birth

MonthDayYear
Date
Contact Number
Email Address
example@example.com
Address

Address

Street Address Line 2

CityState / Province

Postal / Zip Code
State
Zip Code
Emergency Contact Name
Emergency Contact Phone Number
Format: (000) 000-0000.
Confidentiality Agreement:

Your participation in this group is voluntary and confidential. Group sessions aim to provide a supportive environment, and participants are expected to maintain confidentiality regarding any shared information. Confidentiality may be breached only in accordance with California law, such as in cases of suspected abuse, neglect, or imminent danger to self or others.
I acknowledge and agree to:

- Maintain the confidentiality of all group discussions.

- Refrain from recording or sharing session content.

- Understand the limits of confidentiality as outlined above.
Signature

Clear
Date

MonthDayYear
Date
Consent to Participate and Waiver of Liability:

By signing below, I confirm that:

- I am voluntarily participating in this Complimentary Community Group Therapy.

-I understand that this service is provided "asis" for supportive purposes and does not constitute a therapeutic relationship beyond the group sessions.

-I understand that no diagnosis or treatment plans will be created, and participation is not a substitute for ongoing mental health treatment.

- I release Westside Treatment, LLC dba (1) Totality Treatment Center (2) The Heights Treatment - CA and its staff from any liability related to participation in these sessions, including, but not limited to, emotional distress or dissatisfaction with the services provided.

- I agree to adhere to the group's policies and respect the facilitator and other participants.
Signature

Clear
Date

MonthDayYear
Date
Screening Questions
YesNo
YesNo
YesNo
YesNoIf Yes, Please Specify:
5 Please indicate any specific areas of support you are seeking
Grievance Policy:

If you have concerns or grievances regarding these sessions, please contact us directly. All grievances will be addressed promptly and confidentially.

Contact Information for Grievances:

Phone: (310) 400-6244

Email: grievances@totalitytreatment.com

Mail: 11150 W Olympic Blvd, #760,
Los Angeles, CA
90064

Contact Information:
For questions or additional support, please contact us at:
Phone: (855) 619-5383
Email: info@totalitytreatment.com
Address: 11150 W Olympic Blvd, #760,
Los Angeles, CA
90064
Should be Empty:

Intake Form

Screening Questions