Unstuck Registration Form

Unstuck Registration Form

Complete this referral-style intake to help us determine eligibility, payment options, and readiness for the 8-week group.
Basic Information
Full Legal Name

First NameMiddle NameLast Name
Preferred Name
Which Cohort(s) are you interested in

Other
Please upload a copy of the front AND back of your State or Federal ID below

i.e. License, state ID, passport, passport card
File Upload

Cancelof
Pronouns
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Current Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact: Name Name*, Relationship Relationship*, Phone Area Code* Email Phone Number*
Insurance, Self Pay, Scholarships
Are you a North Carolina resident?
How do you plan to pay for the program?
If applying for a scholarship, please share briefly why you are requesting scholarship support.
Insurance carrier
IF USING INSURANCE Please upload a copy of the FRONT and BACK of your insurance card below
File Upload

Cancelof
If self pay, which option do you choose?
Neurodivergent Profile
Do you identify as neurodivergent?
Which identities or experiences apply to you?

Other
What are your primary regulation challenges?
Somatic Safety Screening
Have you ever experienced dissociation or feeling disconnected from your body?
Do you have a trauma history that may impact somatic work?
How comfortable are you with breathwork?
Please list any medical conditions that may affect movement, breath, or grounding practices.
Are there any somatic practices you would prefer to avoid?
Mental Health Pre Screeners
PHQ-2
Over the last 2 weeks, rate each item below.
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
GAD-2
Over the last 2 weeks, rate each item below.
Feeling nervous, anxious, or on edge
Not being able to stop or control worrying
ASRS-5
How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly?
How often do you leave your seat in meetings or other situations in which you are expected to remain seated?
How often do you have difficulty unwinding and relaxing when you have time to yourself?
When you're in a conversation, how often do you find yourself finishing the sentences of the people you are talking to before they can finish them themselves?
How often do you put things off until the last minute?
How often do you depend on others to keep your life in order and attend to details?
Provider Collaboration
Are you currently in individual therapy?
Therapist name

First NameLast Name
Practice name
Therapist contact phone
Please enter a valid phone number.Format: (000) 000-0000.
Would you like to complete an ROI for coordination of care?
Participant Readiness
Why are you interested in joining Unstuck?
What do you hope to gain from this group?
Final Confirmation
Are you able to commit to weekly sessions for 8 weeks?
Do you understand that Unstuck is a therapeutic group and not a replacement for individual therapy?
Attestation: all information provided is accurate
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature
Should be Empty:

Unstuck Registration Form

Basic Information

Please upload a copy of the front AND back of your State or Federal ID below

Insurance, Self Pay, Scholarships

IF USING INSURANCE Please upload a copy of the FRONT and BACK of your insurance card below

Neurodivergent Profile

Somatic Safety Screening

Mental Health Pre Screeners

PHQ-2

GAD-2

ASRS-5

Provider Collaboration

Participant Readiness

Final Confirmation