UNTYING THE KNOTS APPLICATION
(All information will be kept confidential to the Group Facilitators & RHCC Wholeness Dept)
Name:
First and last name
Your answer
Date:
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DOB
Your answer
Email:
Your answer
Phone:
Your answer
Mailing address:
Your answer
Gender:
1. Please describe how you heard about UTK:
Your answer
2. Did someone recommend you participate in UTK?
If YES, who?
Your answer
3. Have you been thru UTK before
Approximate Date:
Your answer
4. Attendance is expected at all sessions, except in the case of illness or emergency. We find it particularly important for group bonding to have everyone commit to attending every session, especially the first two sessions. Is this something you're able to commit to?
If no, please explain:
Your answer
5. Please briefly describe your personal reasons for wanting to be a part of UTK (e.g. what you hope to gain or hope to have happen):
Your answer
6. Do you have a mental illness, including depression, anxiety, Obsessive Compulsive Disorder (OCD) or Bi-Polar Disorder (BPD)? If so, how is it being treated? Do you see any reason why this condition would interfere with your ability to participate in this group?
Your answer
7. Have you ever had any serious thoughts about committing suicide or made a suicide plan or attempt? If so, please describe how and when.
Your answer
8. Are you seeing an individual therapist right now?
If yes, how frequently are you seeing this person? Many individuals find that seeing a therapist while attending the group is very helpful. (This is not a requirement, however.)
Your answer
9. Other Struggles: Are you struggling with any of these: recreational drug or alcohol use, eating disorder, workaholism, sexual addiction, internet addiction, spending addiction, or codependency?
Your answer
9a. Are you receiving support for any of these struggles? Please describe.
Your answer
10. Are you at a time of great stress or important transition in your life?
Your answer
11. Personal Health: Do you have any health issues that may prevent you from attending group regularly?
Your answer
12. Are you currently in an abusive relationship? If so, please describe.
Your answer
13. Is there anything else in your life that may make it difficult for you to concentrate that we should be aware of? (Personal habits or mannerisms, ADD or ADHD, etc.)
Your answer
14. Describe your religious upbringing: (Please note that the group is open to those from all religious backgrounds.)
Your answer
15. I am currently a Rolling Hills (check one): (Rolling Hills attendance is NOT required to participate in the group)
If NEITHER, do you attend another church? (check one:)
If YES, what is the name of the church you attend?
Your answer
16. Untying the Knots of the Heart also has some guidelines that make the process safe and effective. They include: A. Keeping what is shared confidential B. Not giving advice to others or trying to "fix" others C. Focusing on your own issues and learning, not teaching your ideas or trying to identify issues in others D. Respecting others by actively listening, not interrupting or cross-talking. Will you make every effort to abide by these guidelines?
17. Untying the Knots of the Heart is a commitment, sometimes taking up to 12 weeks and up to 2 hours of homework each week. It also includes sharing in a group setting about yourself and your life. To get the most out of the experience, you will need to share about painful or possibly shameful parts of your life. Do you feel you are ready at this point in your life to take on this commitment? (check one:)
Signed (If completing electronically, your typed name will serve as your signature.)
Your answer
Date
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