Group Intake Form

First Name

Last Name

Email

Phone Number

Date of Birth

Gender MaleFemale

Marital Status —Please choose an option—MarriedNever MarriedDivorcedSeparatedWidowed

Number of years Married

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

If Yes, please indicate the date range:

What was the experience like? —Please choose an option—PoorFairGoodVery Good

How is your physical health at present? —Please choose an option—PoorUnsatisfactorySatisfactoryGoodVery Good

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

If Yes, please list:

Have you had suicidal thoughts recently? —Please choose an option—FrequentlySometimesRarelyNever

Have you had suicidal thoughts in the past? —Please choose an option—FrequentlySometimesRarelyNever

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

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?

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?