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WORTH Intake Form

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    WORTH is a PEER SUPPORT GROUP FACILITATED BY QUALIFIED SPECIALISTS intended to help you understand and recover from what is now called “Betrayal Trauma”. IT IS IN NO WAY MEANT TO REPLACE INDIVIDUALIZED THERAPY.


    A significant portion of the financial resources needed to provide this service to you comes from the Men of Moroni Self-Mastery training program. If your husband is in need of this type of training, you can learn more by visiting https://menofmoroni.org/

     

    Both Men of Moroni and the WORTH program are brought to you by Life Changing Services (LifeChangingServices.org).

     

    Please complete the requested fields. Call (801) 923-3026 if you have any questions. PLEASE NOTE: Your registration is not complete until you have an intake phone call with our intake specialist. You will schedule that at the end of this form.

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    Select WORTH if you are still working to save your marriage.  Select WORTH Divorce if you have moved towards divorce in your current marriage.
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    Please list all medications (DRUG NAME, DOSE, FREQUENCY, ROUTE) that you are currently prescribed, if more than one, separate them with a comma.
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    Many of our participants have requested that we share general betrayal trauma information with their church leader. If you would like to have anonymous information shared with your church leader to help support his understanding of betrayal trauma, please provide his email address. To protect your privacy, your name and information will not be shared without your written consent.

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    Please Select
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    • Afghanistan
    • Albania
    • Algeria
    • American Samoa
    • Andorra
    • Angola
    • Anguilla
    • Antigua and Barbuda
    • Argentina
    • Armenia
    • Aruba
    • Australia
    • Austria
    • Azerbaijan
    • The Bahamas
    • Bahrain
    • Bangladesh
    • Barbados
    • Belarus
    • Belgium
    • Belize
    • Benin
    • Bermuda
    • Bhutan
    • Bolivia
    • Bosnia and Herzegovina
    • Botswana
    • Brazil
    • Brunei
    • Bulgaria
    • Burkina Faso
    • Burundi
    • Cambodia
    • Cameroon
    • Canada
    • Cape Verde
    • Cayman Islands
    • Central African Republic
    • Chad
    • Chile
    • China
    • Christmas Island
    • Cocos (Keeling) Islands
    • Colombia
    • Comoros
    • Congo
    • Cook Islands
    • Costa Rica
    • Cote d'Ivoire
    • Croatia
    • Cuba
    • Curaçao
    • Cyprus
    • Czech Republic
    • Democratic Republic of the Congo
    • Denmark
    • Djibouti
    • Dominica
    • Dominican Republic
    • Ecuador
    • Egypt
    • El Salvador
    • Equatorial Guinea
    • Eritrea
    • Estonia
    • Ethiopia
    • Falkland Islands
    • Faroe Islands
    • Fiji
    • Finland
    • France
    • French Polynesia
    • Gabon
    • The Gambia
    • Georgia
    • Germany
    • Ghana
    • Gibraltar
    • Greece
    • Greenland
    • Grenada
    • Guadeloupe
    • Guam
    • Guatemala
    • Guernsey
    • Guinea
    • Guinea-Bissau
    • Guyana
    • Haiti
    • Honduras
    • Hong Kong
    • Hungary
    • Iceland
    • India
    • Indonesia
    • Iran
    • Iraq
    • Ireland
    • Israel
    • Italy
    • Jamaica
    • Japan
    • Jersey
    • Jordan
    • Kazakhstan
    • Kenya
    • Kiribati
    • North Korea
    • South Korea
    • Kosovo
    • Kuwait
    • Kyrgyzstan
    • Laos
    • Latvia
    • Lebanon
    • Lesotho
    • Liberia
    • Libya
    • Liechtenstein
    • Lithuania
    • Luxembourg
    • Macau
    • Macedonia
    • Madagascar
    • Malawi
    • Malaysia
    • Maldives
    • Mali
    • Malta
    • Marshall Islands
    • Martinique
    • Mauritania
    • Mauritius
    • Mayotte
    • Mexico
    • Micronesia
    • Moldova
    • Monaco
    • Mongolia
    • Montenegro
    • Montserrat
    • Morocco
    • Mozambique
    • Myanmar
    • Nagorno-Karabakh
    • Namibia
    • Nauru
    • Nepal
    • Netherlands
    • Netherlands Antilles
    • New Caledonia
    • New Zealand
    • Nicaragua
    • Niger
    • Nigeria
    • Niue
    • Norfolk Island
    • Turkish Republic of Northern Cyprus
    • Northern Mariana
    • Norway
    • Oman
    • Pakistan
    • Palau
    • Palestine
    • Panama
    • Papua New Guinea
    • Paraguay
    • Peru
    • Philippines
    • Pitcairn Islands
    • Poland
    • Portugal
    • Puerto Rico
    • Qatar
    • Republic of the Congo
    • Romania
    • Russia
    • Rwanda
    • Saint Barthelemy
    • Saint Helena
    • Saint Kitts and Nevis
    • Saint Lucia
    • Saint Martin
    • Saint Pierre and Miquelon
    • Saint Vincent and the Grenadines
    • Samoa
    • San Marino
    • Sao Tome and Principe
    • Saudi Arabia
    • Senegal
    • Serbia
    • Seychelles
    • Sierra Leone
    • Singapore
    • Slovakia
    • Slovenia
    • Solomon Islands
    • Somalia
    • Somaliland
    • South Africa
    • South Ossetia
    • South Sudan
    • Spain
    • Sri Lanka
    • Sudan
    • Suriname
    • Svalbard
    • eSwatini
    • Sweden
    • Switzerland
    • Syria
    • Taiwan
    • Tajikistan
    • Tanzania
    • Thailand
    • Timor-Leste
    • Togo
    • Tokelau
    • Tonga
    • Transnistria Pridnestrovie
    • Trinidad and Tobago
    • Tristan da Cunha
    • Tunisia
    • Turkey
    • Turkmenistan
    • Turks and Caicos Islands
    • Tuvalu
    • Uganda
    • Ukraine
    • United Arab Emirates
    • United Kingdom
    • United States
    • Uruguay
    • Uzbekistan
    • Vanuatu
    • Vatican City
    • Venezuela
    • Vietnam
    • British Virgin Islands
    • Isle of Man
    • US Virgin Islands
    • Wallis and Futuna
    • Western Sahara
    • Yemen
    • Zambia
    • Zimbabwe
    • Other
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     Optional if you would like to provide us with the information.
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     Optional if you would like to provide us with the information.
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     Optional if you would like to provide us with the information.
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     Optional if you would like to provide us with the information.
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    Your Signature and Date
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    Your Signature and Date
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    Sign your name and write in today's date
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     ATTENDANCE, CONFIDENTIALITY & ACKNOWLEDGEMENTS


    We welcome you to the Worth Group. 

    Attendance 

    There is a four week attendance policy in the Worth Group. If you are unable to attend your assigned group for four weeks in a row, your name is automatically removed from the roll to make room for another individual who may be waiting to get into a support group. 

    Confidentiality

    We understand the information you share can be very personal and you may not want us to disclose this information to others without your authorization. Life Changing Services personnel will not release confidential information without written authorization, unless such a release is otherwise authorized or required by the law. For example, the law may require us to disclose confidential information if there is a reason to believe that a child has been abused or neglected, or that you may be in danger of harming yourself or others. You may ask your clinician about other laws.

    Grievance

    You have every right to be treated with respect and dignity in a safe environment. Discrimination by our staff is not tolerated. If you have concerns about the services you receive, talk to your counselor or make an appointment with the Life Changing Services director who will assist you.

     

    Acknowledgment

    I understand that Worth is a peer support group facilitated by qualified specialists and is no way meant to replace individualized therapy. 

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    Client or responsible party if client is under 18 and include date
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    You're almost done with your WORTH intake.  Please click below to submit your information.  

     

    IMPORTANT!!! Once you click the Submit button, you will be taken to a booking link where you need to schedule an intake session with our intake coordinator.  

     

    IF YOU DON'T SCHEDULE AN APPOINTMENT, YOUR INTAKE WILL NOT BE COMPLETE. AN INTAKE PHONE CALL IS REQUIRED BEFORE STARTING IN A WORTH GROUP.

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