Barbara’s Lighthouse, 5201- D Nations Ford Road, Charlotte, NC 28214 980-522-8096 email@example.com
Group Admission Form
ADDRESS:_________________________________ Male_______ Female_______
CITY:________________________________ DATE OF BIRTH:_________________
STATE:_______________ ZIP:______________ EMAIL:______________________
HOME PHONE:______________________ CELL PHONE:_____________________
In case of emergency, notify:_____________________________________________________________
Living Arrangements: Education:
❑ Alone ❑ G.E.D. ❑ HS Diploma ❑ With parents ❑ Bachelors ❑ Masters ❑ With spouse
Student in Education/Training Yes______ No______ ❑ Children ❑ With friends ❑ Other_____________________
ETHNIC BACKGROUND MARITAL STATUS RELIGIOUS PREFERENCE
_________________________ _________________________ _________________________
EMPLOYMENT STATUS OCCUPATION_______________________________________
_____ Full time ______ Part time ______ Unemployed ______ Fired ______ Laid off
WHY DO YOU WANT TO ATTEND THIS GROUP:
ARE YOU CURRENTLY ON ANY MEDICATIONS: (please list medication and for what reason you are taking them)
DO YOU USE ALCOHOL? _______Yes ______ No
If yes, what type of alcohol and how much do you drink per week:________________________________
DO YOU USE DRUGS? ______ Yes ______ No
If yes, which drugs do you use and how often:_______________________________________________
PLEASE WRITE A BRIEF DESCRIPTION OF YOURSELF:
IN WHICH WAYS DO YOU FEEL POWERLESS?
WHAT DO YOU BELIEVE YOUR MAIN STRENGTHS TO BE?
WHAT ARE YOUR GOALS?
As a part of group participation, I agree to the following:
1. Respectful and honorable behavior towards each member of the group
2. Commitment to attend all group sessions
3. Read all materials as assigned. Come to group prepared to learn and discuss the week’s
4. Make payment for services each week unless other arrangements have been made in advance
5. Come to group on time.
6. Talk to the group leader about any problems or frustrations I may be experiencing in the group.
7. Fill out and return the Life History Form and Informed Consent Form to the group leader before
the program begins.
________________________________________ ________________________________ Applicant Signature Date