• Childhood Trauma Recovery Group Intake Questionnaire

    Thank you for filling out these questions to the best of your ability. The answers to these questions will be part of how I will assess your readiness and appropriateness for the upcoming group.
  • I have difficulty connecting with myself or others.*
  • Most days I struggle with daily functioning (Lateness, organization, follow through, etc.)*
  • Therapy has not been beneficial for me in the past.*
  • I struggle with dissociation (feeling outside of my body and not connecting).*
  • I am overwhelmed with stress most days.*
  • I am seeking expediated short-term change.*
  • My problems are more situational vs. emotionally internal.*
  • I do not know how my childhood has impacted me.*
  • I currently have legal problems.*
  • I currently have problems of safety (ie. domestic violence).*
  • I am currently in a contentious divorce.*
  • I question my relationship to sex (shut down or compulsive).*
  • I did not seek this out on my own, it was suggested to me to do childhood trauma work.*
  • I have experienced suicidality in the last year.*
  • I've needed partial or inpatient hospitalization in the last year.*

  • Thank you for completing this assessment!

    You will be contacted shortly to schedule an intake appointment if it is determined that you are a good fit for the group at this time. Please email me at marissa@wholeheartedhealingbc.com if you have any further questions.
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