First name*

Last name*

Address line 1*

Address line 2

City*

State*

ZIP*

Country*

Phone number*

Email address*

Emergency contact name*

Emergency contact phone number*

How did you hear about our groups/workshops?*

Would you like to be included on our email list about future events?*
—Please choose an option—YesNo

Please indicate which group/workshop you will be attending*

Your willingness to answer the questions below will help us best assess your readiness for a group/workshop experience such as this. Thank you so much for your cooperation in answering these questions:

Have you ever seen a mental health professional (psychiatrist, psychologist, marriage and family therapist, social worker, counselor)?
—Please choose an option—YesNo

Do you have a therapist you could work with if something came up in this workshop requiring individual/couple attention?
—Please choose an option—YesNo

Are you currently taking any medication for mental health issues?
—Please choose an option—YesNo

Are you in recovery from substance or alcohol abuse? If so, how long have you been sober? Please provide a brief description of the treatment and support you receive for maintaining sobriety?

Do you have a history of eating disorders or disordered eating? If so, please provide information on the support and treatment you are/have received.

Have you experienced distressing life events (trauma, loss, etc.) that have significantly impacted your functioning and quality of life? If so, please provide information about how you have addressed these issues.

What sparked your interest in this group/workshop?

What would you like to accomplish as a result of attending this group/workshop?

Have you had previous experience with group therapy or a support group?
—Please choose an option—YesNo

What concerns, if any, do you have about participating in a group experience?

How would you respond as a group member if someone in the group dominated the discussion?

How would you respond as a group member if someone never participated in the group discussion?

What else would you like us to know about you?

Thank you so much for providing this information! We will review the information you provided and follow up with you to confirm your registration.

For questions or more information you may contact me at nschornack@secondjourneycounseling.com.