Group Intake Form

To register your interest in participating in group sessions please fill out the form below with your background information, intentions and interest. We will note your interests and reach out to you when a group with a relevant topic is being offered and provide more details.

Please note that all information provided will be kept confidential and used only for session design  purposes. If we need additional information from you, we may  schedule a consultation to discuss your participation in group sessions.

    Background Information

    First Name

    Last Name

    Email

    Phone Number

    Date of Birth

    Gender MaleFemale

    Marital Status

    Number of years Married

     

    Counseling Background and Health Information

    Have you attended professional counseling or psychotherapy before? ...YesNo

    If Yes, please indicate the date range:

    From

    To

    What was the experience like?

    How is your physical health at present?

    Are you currently taking prescribed medication (including antidepressants, supplements or birth control)? ...YesNo

    If Yes, please list:

    Have you had suicidal thoughts recently?

    Have you had suicidal thoughts in the past?

     

    Social Support

    Who are the significant people in your life?: (Please specify relationship--spouse, partner, friend, sibling, parent, guardian, etc.)

     

    Goals, Intentions, and Expectations

    What are your main goals or objectives for participating in group sessions?

    Do you have any specific expectations for group sessions?

    What specific challenges or obstacles are you currently facing that you hope to address in the group sessions?

    Do you have any preferences or concerns about participating in a group setting?

     

    Topics

    Please select the topics/issues you would like to address in group sessions (select all that apply): Heart centered relationshipsHealing our relationship with AllahProcessing GriefHealthy postpartum transitionMenstrual cycle literacy and connectionManhood/brotherhoodParenting

    Other(s):

    Is there anything else you would like us to know before starting group sessions?