Finding Calm: Support Group Intake
Please answer all required fields and review the consent statements carefully.
Client Information
Name
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First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Pronouns
Will you be using insurance or private pay? If insurance, which one?
Motivation and Background
What drew you to this group?
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What are you hoping to gain from participating?
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Have you participated in any of the following before?
Support group
Therapy group
Retreat
Other
What do you currently do to manage anxiety in your life:
Are there particular topics, patterns, or areas of growth you're interested in exploring?
Current Support and Facilitator Notes
Are you currently working with a therapist, counselor, coach, or other support professional?
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Yes
No
If yes, feel free to share more
Is there anything you'd like the facilitators to know that would help support your participation in the group?
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Consent and Acknowledgements
Initials: I understand this is a support and personal growth group, not psychotherapy.
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Initials: I understand that group members are asked to respect the confidentiality of others.
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Initials: I understand that participation is voluntary and that I may choose my level of sharing.
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Initials: I understand that consistent attendance helps create a supportive group experience for everyone.
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