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Shark Cage Group Program Intake Assessment form.
Registration for Shark Cage group ( Next Group September 2025)
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Email *
Todays Date *
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Your Full Name *
Date of Birth *
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Your Phone number *
Email *
Address *
Permission to send material to address *
Required
Emergency Contact Name *
Emergency Contact Relationship *
Emergency Contact Number *
What are some of your hopes about coming to the Shark Cage group? *
What are some of your fears and worries about coming to the group? *
Current Circumstances:
Is there anything happening in your life right now that would be helpful or important for Shark Cage facilitators to know?
 *
Safety: Are you currently safe from violence? *
If you responded 'No' and you are at risk of Violence - so you have a safety plan and/or intervention order? *
Details of your safety plan and/or intervention order 
( please note : a copy of any intervention orders are required at start of group- please bring these with you)
 *
If you do not have a safety plan are you willing to work with someone to create a safety plan? *
What do you think you will need to feel safe and able to participate in the group? *
Confidentiality. 
For everyone to be physically and emotionally safe it is important that all members understand and agree to strict confidentiality. 
You cannot talk about others in the group in any way which may identify them. This means you cant say what they look like, where they live or how many kids they may have. 

You will be asked to sign a confidentiality agreement in the first session of the group program 

( do you have any questions or concerns about this?)
 *
Duty of Care: 
Your information is kept confidential. However if at any point Shark Cage facilitators feel that you, or someone else, is at serious risk of harm- 
we may need to break confidentiality to involve your support people or other services to keep you or someone else safe.

Do you have any questions about this?
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Abuse Background. 
Could you please give a VERY BRIEF outline of your experiences of family violence or abuse/sexual assault ?

 Just time periods and perpetrators is enough ( We dont need names or much detail)
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Impacts
Its common for violence and sexual assault to have an impact on people. 

Do you feel you can explain some of impacts on you? 

( For example people often describe experiencing anxiety, depression, trust issues, self esteem problems and/or post traumatic stress.) 

How have your experiences of abuse impacted you?
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Mental Health: Have you received a mental health diagnosis?  *
If yes to a diagnosis , please provide details ( Diagnosis, Year of Diagnosis, Diagnosis given by , Medications currently prescribed) *
Current Coping Strategies. People use all kinds of ways to manage impacts of abuse in their lives. ( for example - therapy, art, exercise, work, parenting, alcohol, drugs, gambling, self harm). 
Do you use any of these coping strategies?
What other coping strategies do you use?
Please list all that you use.
 *
Supports. 
Group work is a powerful help to healing. It can also be challenging at times. 
Its important to be sure you have personal and professional support in your life before starting group.

Please list the supports you have in your life?
 *
Do you give permission to contact a key support person if you need some extra support that week? 

(Please note all participants will also be required to sign a standard release of information form on day one of group which lists emergency contact person and any other important services and personal supports)
 *
Required
Capacity for emotional containment:
The group comes together to provide a safe nurturing space to learn and heal.
The Shark Cage group is NOT a place to talk about the details of any abuse or violence you have experienced- it is a structured group with focus on education and skills training.
It is very important that all group members understand that it is ok to talk about the impact of the experiences- not the details of the events.
If necessary it is also important that group members give facilitators permission to step in and help with this if they are struggling.
The Shark Cage group program aims to help women feel safe and contained while working through impacts of painful experiences.

What are YOUR thoughts about your ability to contain impulse to talk about powerful memories that may come up?
Would you feel ok with a facilitator stepping in to help you if you are struggling with this?
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Attendance.
This is a closed short-term group which needs consistent attendance.

Do you think you will be able to attend all the group sessions?
Can you think of anything that will make it difficult for you to attend all sessions?
Is there anything you can do to reduce barriers to attendance?
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Questions.
Do you have any questions?
 *
Thank you for your time and patience filling in this form. it is really important that we make sure everyone is feeling safe and supported and ready for this group program.

Process.
Please also take time, over the next few days, to think about whether this group feels right to you at this point in your healing journey?

A Shark Cage facilitator will contact you by email or text within the next week to discuss any questions, concerns, expectations or needs you may have,
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