Counseling Group Registration Form
The purpose of these questions in the registration is to obtain a comprehensive understanding of your life experience, background, and medical health issues. Responding to these questions as completely as you can will help us determine if the group will be the best fit for you and your needs. It allows us to gain an understanding of the problems for which you are seeking help and of important events in your life. Some of the questions deal with alcohol and drug use, depression and suicide, and being the victim of a violent crime, including sexual assault. These questions might make you feel uncomfortable. You may skip any question you do not wish to answer. Your responses will remain strictly confidential and will become part of your electronic health record and will not be shared with anyone outside of the counseling division. If you have any questions regarding completing this form please reach out to us at 815-221-6022.
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
What is your preferred language?
Insurance
Name of Insurance Provider
Member ID Number
Group Number
Challenges
If you wish not to disclose personal information, you don't need to answer. Please move to the next question.
Why are you registering for this group?
How long have you been experiencing concerns as it relates to to the issue above?
Less than 30 day
1-6 months
6-12 months
1-5 years
5+ years
Rate the intensity of the problem:
Mild
1
2
3
4
Severe
5
1 is Mild, 5 is Severe
How is the problem interfering with your day-to-day functioning?
What are you hoping to get out of the group?
Are you currently or in the last 30 days experienced any of the following symptoms? (check all that apply)
Sadness
No Motivation
Not Hungry
No Need for Sleep
Suspicious
People Out to GetMe
Easily Startled
Hopeless/Helpless
Lack of Interest
Prefer Being Alone
Talk Too Fast
Hearing Things
Feeling Nervous
Avoidance
Sleep Too Much
Thoughts of dying
Irritable/Angry
Impulsive
Seeing Things
Fearful
Re-occurringNightmares
Fatigue/No Energy
Guilt
Can’t Sleep
Can’t Concentrate
Have Special Powers
Panic Attacks
Poor Memory
Feel Worthless
Too Much Energy
Restless/Can’t Sit Still
People Watching Me
Can’t be in Crowds
Do you now or have you ever contemplated suicide?
Yes
No
Are you a survivor of trauma?
Yes
No
Has your physical health kept you from participating in activities?
Yes
No
Substance Use
Would you or someone you know say you are having a problem with drugs or alcohol?
Yes.
No.
Would you or someone you know say you are having problems with pills or illegal drugs?
Yes
No
Would you or someone you know say you are having problems with other addictions, ie.gambling, pornography or shopping?
Yes
No
Have you ever been to a self-help group?
Yes
No
Is there a family history of addiction in your family?
Yes
No
Please describe the history of addiction in your family.
Relationships
How many people live the home with you?
Has there been any significant person or family member enter or leave your life in the last 90 days?
Yes
No
How are the relationships amongst the members of your immediate family?
Please Select
Good
Fair
Poor
Close
Stressful
Distant
Other
How are the relationships in your support system (friends, extended family, etc?
Please Select
Good
Fair
Poor
Close
Stressful
Distant
Other
Are there any problems in your family now? (check all that apply)
Conflict
Abuse
Stress
Loss
Other
Were there any problems with your family in the past? (check all that apply)
Conflict
Abuse
Stress
Loss
Other
Are there any problems in your support system now? (check all that apply)
Conflict
Abuse
Stress
Loss
Other
Were there any problems with your support system in the past?
Conflict
Abuse
Stress
Loss
Other
What is your marital status now?
Single
Married
Living as Married
Divorced
Widowed
Never Married
Have you ever had problems with marriage/relationships?
Yes
No
N/A
If yes, please check why:
Stress
Conflict
Loss
Divorced/Separation
Trust Issues
Other
Do you have any close friends?
Yes
No
Do you have problems with friendships?
Yes
No
N/A
Do you get along well with others (neighbors, co-workers, etc.)?
Yes
No
N/A
What do you like to do for fun?
Education
What is the highest grade you completed in school?
No Education
K-5
6-8
9-12
GED
College Degree
Masters Degree
What is the highest grade you completed in school?
Please Select
No Education
K-5
6-8
9-12
GED
College Degree
Masters Degree
Would you describe your school experience as positive or negative? (Please explain)
Are you currently in school or a training program?
Yes
No
Legal
Have you ever been arrested?
Yes
No
How many times have you been arrested?
Have you been arrested in the past year?
Yes
No
How many times have you been arrested in the past year?
Have you been arrested in the past month?
Yes
No
How many times have you been arrested in the past month?
What have you been arrested for?
What is/was the name(s) of your attorney(s)?
Were you ever sentenced for a crime?
Yes
No
Number of prison sentences served:
In what year(s) did this occur?
Are you currently or have you ever been on probation or parole?
Yes
No
What is the name of your attorney or probation officer?
Work
What is your work history like?
Please Select
Good
Poor
Sporadic
Other
How long do you normally keep a job?
Please Select
Weeks
Months
Years
Are you retired?
Yes
No
N/A
What kind of work do you do/did you do in the past?
Have you ever served in the military?
Yes
No
Are you:
Active
Retired
Other
Medical
Do you have any medical concerns?
Yes
No
Have you seen a Mental Health Professional before?
Yes
No
Please list the name(s) of the professionals, when you saw them, and your reason for changing.
Current Psychiatrist/APRN, if applicable:
Other
If there's anything else you would like us to know, please include it here:
Submit
Submit
Should be Empty: