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Tabula Rasa Counseling Group Screening
DID Support Group Screening
These questions aim to ensure that potential group members are well-suited for the group’s goals to support and be supported while gaining and sharing skills towards dissociation.  
It is mandatory to have an individual therapist and allow for coordination of care to be in this group. A certain level of stability is required to participate in this group to ensure the emotional safety of others. If you are having active suicide attempts or a recent attempt, you will be asked to stabilize for at least 3 months before joining the group.
Please answer all of the following questions
Email *
First and Last Name *
Date of birth *
phone number *
How did you hear about this group? *
This is a private pay only group. Please note I cannot accept payment if you are enrolled in Medicaid and an opt out form is mandatory if you are enrolled in Medicare *
Which group are you looking to join? *
Are you willing to commit to 8 weeks of group to the best of your ability? *
Have you been formally diagnosed with Dissociative Identity Disorder (DID) by a healthcare professional? *
When were you diagnosed and by whom? *
Have you taken the MID ( multi phasic inventory of dissociation)? *
If so, would you be willing to release the scoring to Cara Czarnecki, LPC *
Are you currently in individual therapy? *
Do you agree to sign a release for Cara to have contact with your therapist? *
What kind of treatment are you currently doing? (parts work, EMDR, etc) *
Have you previously participated in any support groups or therapy specifically for DID? If yes, what was your experience? *
How would you describe your understanding of Dissociative Identity Disorder and its symptoms? *

What do you hope to gain from being part of this group?

 *
What specific types of support are you looking for in this group (e.g., emotional support, coping strategies, shared experiences)? *
Are there any particular issues or topics you feel are important to address in this group? *
Are there any topics or triggers you prefer to avoid or discuss with caution? *
Are you open to both giving and receiving feedback and support within the group? *
Do you have a support system or plan in place for managing crises outside of the group? *
Please explain *
Are you currently experiencing active suicidal ideation *
Have you have any suicide attempts? If so, when was the last date? *
MM
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DD
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Have you been hospitalized for mental health reasons in that last year? *
Do you have a safety plan in place with you current therapist or on your own? *
If yes, please explain what the steps are. If no, a safety plan will be required before entry to group but can be done by appt with Cara *
How do you usually handle crises or intense emotional experiences related to your DID? *
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