Group Therapy Interest Survey
Purpose In Play: To Graduation & Beyond
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Parent/Guardian Name
*
Phone Number
*
Format: (000) 000-0000.
Parent/Guardian Phone Number
*
Email
*
example@example.com
Is your parent/guardian aware of this referral:
Yes
No
Gender
Male
Female
Non-binary
Prefer not to say
Insurance Type & Member Id (if Member ID unknown input Type only [e.g., Medicaid])
*
Group Therapy Preferences:
Topics of Interest (Check all that apply)
*
Career Assessments (Find out what I like)
Job Shadowing
Credit, saving & avoiding debt
Making a home away from home
Time management
Professional communication & workplace etiquette
Resume building & job applications
Undecided next steps
Other
Have you ever participated in a group before?
*
Yes
No
Preferred Day for Group Sessions
*
Monday (6:00-7:00 PM)
Tuesday (6:00-7:00 PM)
Wednesday (6:00-7:00 PM)
Thursday (6:00-7:00 PM)
Friday (6:00-7:00 PM)
Saturday (9:00-10:00 AM)
Sunday (3:30-4:30 PM)
Goals and Expectations:
What are your goals for participating in group therapy?
What do you hope to gain from the group experience?
Is there anything specific you would like the facilitator to know about your preferences or needs in a group setting?
Signature
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