Young Adult Workshop Questionnaire

Young Adult Workshop Questionnaire
Participant Information
Participant's name

First NameLast Name
Phone Number:
Format: (000) 000-0000.
Email Address:
example@example.com
Preferred Contact Method (Circle):
Parent/Guardian Name(s) (if under the age of 18):

First NameLast Name
Phone Number:
Format: (000) 000-0000.
Email Address:
example@example.com
Preferred Contact Method (Circle):
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you hear about our Young Adult Workshops?
Date of Birth:

MonthDayYear
Date
Age:
Gender:
Highest level of education achieved:
If you have an IEP/504 Plan or other services, please briefly describe accommodations or services:
Family & Household Information
Who lives in the household with you?
Primary language(s) spoken at home:
Are there any significant family changes or stressors we should be aware of (e.g., divorce, relocation, illness, loss)?
Developmental & Medical History
Have you received any diagnoses? If yes, please describe (e.g., ADHD, Autism Spectrum Disorder, anxiety, depression, learning disability):
Are you currently receiving any therapeutic services? (e.g., counseling, occupational therapy, speech therapy, tutoring) If yes, please describe:
Are you currently taking any medications? If yes, please list medication name(s) and purpose:
Are there any medical conditions, allergies, or physical health concerns we should know about? If yes, please describe:
Social & Emotional Functioning
Social, Occupational, Health Challenges: What social or emotional difficulties do you currently experience? (Check all that apply)

Other
Emotional Regulation: How do you typically handle big emotions (anger, sadness, frustration, excitement)?

Young Adult Workshop Questionnaire
Behavioral Concerns
Do you have any behavioral challenges at home, work or school (e.g., defiance, aggression, withdrawal, avoidance)? If yes, please describe:
How do you handle feedback, redirection, or correction?
Goals & Expectations
Previous Group or Therapeutic Experience: Have you participated in therapy groups before? If yes, what worked well? What didn't work?
Additional Information
What are your goals for attending these workshops?
Does you have any sensory sensitivities to sound, touch, textures, smells, etc.?
Is there anything else we should know about you that would help us support you effectively?
Consent & Next Steps
By submitting this questionnaire, I understand that Triumph Center staff will review this information to determine my appropriateness for this group. I consent to being contacted to discuss next steps.
Parent/Guardian or Participant Signature:
Date:

MonthDayYear
Date
I consent to receiving email communication from the Triumph Center related to scheduling, reminders, materials, and participation in this workshop series
Should be Empty: