Barbara’s Lighthouse,  5201- D Nations Ford Road, Charlotte, NC 28214 980-522-8096 delisafields93@gmail.com

Group Admission Form

NAME:_____________________________________ DATE:____________________

ADDRESS:_________________________________ Male_______ Female_______

CITY:________________________________ DATE OF BIRTH:_________________

STATE:_______________ ZIP:______________ EMAIL:______________________

HOME PHONE:______________________ CELL PHONE:_____________________

REFERRAL SOURCE:___________________________________________________

In case of emergency, notify:_____________________________________________________________

Phone:__________________________ Relationship:__________________

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

Homework.

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