Group Therapy Screening Survey

Group Therapy Screening Survey

Please complete this form to help us assess your suitability for the therapy group.
Basic Information
Full Name*

First NameMiddle NameLast Name
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Age
City / Area
Have you participated in therapy before?*

Yes – IndividualYes – GroupBothNo
Presenting Concerns
What brings you to consider joining this group?*
What challenges are you currently experiencing?*
How are these challenges affecting your relationships with others?*
Interpersonal Patterns
How would you describe yourself in relationships?*
Do you find it easy or difficult to open up to people? Why?*
When there is conflict, how do you usually respond?*

Avoid itAddress it directlyWithdrawBecome emotionalOther
How do you think others experience you in relationships?*
Emotional Awareness
How comfortable are you expressing your emotions to others?*

Very comfortableSomewhat comfortableNot comfortable
What emotions do you find most difficult to express?
What do you usually do when you feel uncomfortable or vulnerable?
Readiness for Group Work
How do you feel about a group setting that includes open discussion and interaction with others?*
Are you open to receiving feedback from others about how you come across?*

YesSomewhatNo
How do you typically respond to feedback or criticism?*
Here-and-Now Engagement
Are you open to discussing your reactions to others during sessions as they happen?*

YesSomewhatNo
How comfortable are you talking about your thoughts and feelings in the moment?
Commitment
Able to commit to a 6-month weekly group schedule?*

YesNoUnsure
What might make it difficult for you to attend consistently?
What are you hoping to gain from the group?
Mental Health & Safety
Are you currently experiencing any of the following?*

DepressionAnxietyThoughts of harming yourselfSubstance use concernsSignificant emotional distressPsychosis (e.g., hallucinations, difficulty distinguishing reality)Paranoia (e.g., feeling watched, unsafe, or mistrustful of others)None
If you selected any of the above, briefly describe your current experience.
Are you currently receiving any mental health support (e.g., therapy, counselling, psychiatry)?
Are you currently taking any medications related to your mental health?
Mental Health History
Have you ever been diagnosed with a mental health condition?*

YesNoUnsure
If known, what diagnosis or diagnoses have you received?
Have you ever been hospitalized for mental health concerns? Please explain.
Anything else about your mental health history that would be important for the therapist to know when considering your participation?
Alcohol Use
How often do you consume alcohol?*

NeverOccasionallyWeeklyDaily
Does alcohol affect your relationships or emotional wellbeing?
Have others expressed concern about your alcohol use?
Motivation & Fit
Why do you want to join this group specifically?*
What does being part of a group mean to you?*
What would make this group successful for you?*
Should be Empty:

Group Therapy Screening Survey

Basic Information

Presenting Concerns

Interpersonal Patterns

Emotional Awareness

Readiness for Group Work

Here-and-Now Engagement

Commitment

Mental Health & Safety

Mental Health History

Alcohol Use

Motivation & Fit