Its Fine Group Therapy

Name*

First NameLast Name

Phone Number*

Email Address*

we do not share information with 3rd parties

Preferred Pronouns

Birthdate**

must be 18 or over

Emergency Contact*

First NameLast Name

Emergency Contact Phone #*

Please enter a valid phone number.

Please select your preferred form of communication for administrative/scheduling issues (not personal information or emergencies). Emergencies should be handled via telephone call.*

Email address listed aboveText phone number listed above

Have you ever attended the "It's Fine" group therapy with Marjorie Taylor?*

Yes (go to date selection)No (complete one time intake form)

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please respond to the following questions honestly and to the best of your ability. Responses are subject to HIPPA regulations. Only Marjorie will receive the details of the intake form. The purpose of this intake is to evaluate a potential member's suitability for the group and ensure the setting aligns with their needs.

I have received a copy of the HIPPA Privacy Notice Form

Have you ever received psychiatric or psychological help or counseling?*

YesNo

Provide your diagnosis, therapist's name and approximate dates.

Do you have a history of suicide attempts?*

YesNo

If so, please explain circumstances (including date, method and treatment received).

Do you have current suicidal ideation?*

YesNo

Do you have a plan for suicidal ideation?*

YesNo

Do you have homicidal ideation?*

YesNo

Do you have a plan for the homicidal ideation?*

YesNo

Have you been a victim of physical, sexual or emotional abuse?*

YesNo

Do you have any medical issues or diagnoses that we should be aware of for your safety? (ie: food allergies, seizure disorder). If so please list them here.

Please indicate how often you have been bothered by the following problems over the last 2 weeks:*

	Not at all	Several Days	More than half the days	Nearly every day
Little interest or pleasure in doing things
Feeling down, depressed or hopeless
Trouble falling asleep, staying asleep or sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself - or that you are a failure or have let yourself or your family down
Trouble concentrating on things, such as reading the newspaper or watching TV
Moving or speaking so slowly that other people could have noticed? Or the opposite - being so fidgety or restless you are moving around much more than usual
Thoughts that you would be better off dead or of hurting yourself in some way.

If you checked off ANY problems above how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

Not difficult at allSomewhat difficultVery difficultExtremely difficult

Please indicate how often you have been bothered by the following problems over the last 2 weeks:*

	Not at all	Several Days	More than half the days	Nearly every day
Feeling nervous, anxious or on edge
Not being able to stop or control worrying
Worrying too much about different things
Trouble relaxing
Being so restless it is hard to sit still
Becoming easily annoyed or irritable
Feeling afraid as if something awful might happen

When completing this section "drug use" includes illegal drug use and prescription drug use other than as prescribed:*

	Yes	No
Have you ever felt that you ought to cut down on your drinking or drug use?
Have people annoyed you by criticizing your drinking or drug use?
Have you ever felt bad or guilty about your drinking or drug use?
Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover?

Group Environment and Emotional Safety:

A support group brings together individuals from diverse backgrounds and experiences. It is essential that all members treat each other with respect, empathy, and acceptance. All participants are expected to strive to create an atmosphere free from judgment, creating a safe space for individuals to express themselves without fear of criticism or ridicule.

The facilitator will ensure that the environment remains a physically and emotionally safe space for the benefit of the group and the individuals within it. If a disruption should occur, the facilitator will ensure the necessary action is taken to restore safety and support any individuals affected.

Violent, hostile, or threatening behavior of any kind is not tolerated at Eclipse.

Please note: The art therapy groups at Eclipse are designed to provide services on an outpatient basis. Individuals requiring a higher level of care, such as partial hospitalization, will be referred to a local emergency room for assessment.

I hereby acknowledge that I have read and understand the Group Environment & Emotional Safety statement above.*

I hereby give consent to Marjorie Taylor to use photos and/or images of my artwork, for purposes of record keeping without any concern for remuneration. I understand that any identifying information will be removed or disguised, which protects the confidentiality of participants/clients. I understand that I can withdraw this consent in writing any time prior to the use of the material. *

Please read the Group Therapy Consent to Treatment form.

Your signature indicates that you have read the Consent to Treatment form and agree to abide by its terms. *

Please select date(s) you would like to attend. You must reserve your space by the Wednesday before the session. You do not have to commit to more than one date at a time. *

It's Fine..Friday Feb 27

$25

It's Fine..Friday March 13

$25

It's Fine..Friday March 27

$25

It's Fine..Friday April 10

$25

It's Fine..Friday April 24

$25

It's Fine..Friday May 8

$25

It's Fine..Friday June 12

$25

It's Fine..Friday June 27

$25

Enter coupon

Total

$0.00

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It's Fine . . .

Group Therapy Intake Information

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