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Group Therapy Prescreening Form
Event Timing: September 2025 (8 occurrences/ weekly sessions)
Event Address: 231 Fredrick St, Unit 3, Kitchener, ON N2H 2M7
Contact Us: (519) 804-6545, info@streettherapy.ca
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Thank you for your interest in participating in group therapy. This form helps us understand your current needs, treatment history, and group readiness. The information you share will be reviewed by a clinician to determine:
Whether group therapy is a clinically appropriate and supportive option for you at this time. If another service, such as individual therapy, might be more beneficial based on your goals and current symptoms.
The best fit between you and the group based on the group’s structure, focus, and participants’ readiness and needs.
Your responses will remain confidential and are used solely for clinical matching and safety purposes. If we have any questions or need more information, we may reach out to schedule a brief screening conversation.
Please Note:
To help ensure a safe and supportive environment for all participants, individuals who are currently experiencing active suicidal thoughts with intent or plan, ongoing self-harming behaviours, or unstable mental health symptoms that require more intensive support will be better served through individual therapy and a higher level of care before participating in a group. This decision is always made with your wellbeing in mind.

Please complete this form as fully and openly as possible. We will follow-up with you to discuss treatment options, to fill out additional forms, or provide instructions for the group therapy. Please save our email addresses (info@streettherapy.ca) to ensure you receive important updates and program materials. 
Todays Date *
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Your Full Name *
Date of Birth *
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Age/ Gender/ Pronouns *
Home Address, City, Postal Code
 *
Email *
Phone number (Can we leave you a message?)
 *
Currently employed? Yes/No, Occupation
 *
Currently a student? Yes/No, Program
Who lives with you?  Name/ Age/ Relationship  
 *
Emergency Contact Information *
Current Mental Health and Treatment
Are you currently receiving individual therapy? If yes,  please provide your therapist’s name and contact (optional): *
Are you currently taking any psychiatric medication? If yes, please list (optional) *
Do you have any current or past mental health diagnoses? If yes, please describe if comfortable.  *
Are you experiencing any of the following? (Check all that apply) *
Required
Refferal and Interest
How did you hear about us?
Clear selection
What interests you about participating in this group? 
Have you participated in group therapy before?
Clear selection
Group Readiness
Are you comfortable sharing personal experiences in a group setting? *
What are your goals for participating in this group? *
What are your concerns if any, about participating in this group?
 Are you able to commit to attending weekly sessions for the duration of the group? *
Logistical Needs 
Do you have any accessibility needs (e.g., mobility, hearing, language support)? If yes, please explain:
Preffered Group Format *
Will you require receipts (to be submitted to insurance coverage) for your participation in the group therapy? *
Additional Notes/ Questions for the Facilitator:
After reviewing your responses, we will contact you to:
- Confirm whether the group seems like a good clinical fit.
- Explore any concerns or questions you may have.
- Discuss alternative or additional supports if needed (e.g., individual therapy, a different group).
Completing this form does not guarantee admission into the group. Matching is based on clinical fit, group composition, and availability. 
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