Intake Form for Potential Group… | Willamette Christian Church

Name

First Name

Last Name

Address

Address 1

Address 2

City

ZIP Code

State

Phone

Email Address

Years Married

Years Divorced

If you are currently married, does your spouse know that you are interested in attending a Mending the Soul group?

Yes

You are not required to tell them, but unless we know otherwise, we will assume that they know and are supportive.

Please briefly describe your story of pain or abuse and why you are interested in attending a small group for healing.

How would you describe your personal health? Do you have any health issues that may prevent you from attending group regularly?

Regular attendance is very important in the small group setting.

Behavioral Support

The effects of abuse sometimes lead to other struggles that we are not equipped to handle during small group meetings. Are you struggling with any behaviors with which you may need some extra support, including (but not limited to), drug or alcohol addiction, sexual addiction, an untreated eating disorder, etc.? If yes, are you receiving support for any of these struggles? Please explain.

Are you currently in an abusive relationship? If so, please explain.

Are you experiencing a great amount of stress or significant transition at this time in your life?

Have you ever had any serious thoughts about committing suicide or made a suicide plan or attempt? If so, please describe how and when.

Mental Health History

Have you ever been diagnosed with a mental illness including (but not limited to) depression, and anxiety disorder, bipolar, etc.? If so, how is it being treated? Do you see any reason why this condition would interfere with your ability to complete the material required for this group?

Is there anything else in your life that might make it difficult for you to concentrate that your facilitators should be aware of?

Personal habits or mannerisms, ADD or ADHD, etc.

Have you ever received counseling?

Yes

Including professional, lay and pastoral counseling.

Counseling History

Type	Year(s)	Purpose	Approx. # of Sessions

Describe your religious upbringing.

Please note that this group is open to those from all religious backgrounds. Abuse wounds the spirit and the soul.

What is your perception of God?

Do you have a church home?

Yes

Church Name

Intake Form for Potential Group Participants