STRONGER AFTER
INTAKE FORM

Your Privacy: We take your privacy seriously. This intake questionnaire will only be accessed by the Stronger After Coaching Supervisor in order to contact you. After you have been paired up with a coach, only your coach will look at your intake questionnaire. Your name, email address, or information will not be shared with any third parties.

DISCLAIMER: Stronger After is a form of coaching and is in no way to be considered or substituted for psychological counseling or any other type of therapy or medical advice.
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* 1. In what areas did you experience coercive control? *
Required
How did you become involved in the group or relationship? *
*
If you answered " I have left," please specify how long ago:
How did you leave? *
Which types of abuse would you say you have experienced while in this situation? (Check all that apply) *
Required
How often are you bothered by the following experiences? (Check each column as it applies) *
never
sometimes
often
always
not sure what the question means
Thoughts keep circling in my head. I can't make them stop.
I don't think I am worthy of love
I have nightmares
I have fears about the world ending, hell, karma or other punishment
I fear making mistakes
I feel shame for having participated
I experience difficulty making decisions
I feel a sense of dread
I experience anxiety and panic
I feel guilt for leaving the situation
I feel guilty for leaving people behind
I feel guilty for living / enjoying life
I have an internal voice that criticizes me or polices me
I feel alone / miss my community
I have strong beliefs and inner convictions that I didn't choose
I feel responsible for others and their needs
I lack boundaries and don't feel sure when someone is violating mine
I have difficulty connecting with other people
I have difficulty with sexuality and physical closeness
I have difficulty trusting others
I have difficulty finding a job or being able to keep it
I have issues with authority in the workplace or elsewhere
I have difficulty speaking up and not letting others take advantage of me
I have suicidal thoughts
I sometimes hurt myself
I feel exhausted
I feel stress from family who are still in the group or situation
I have no sense of who I am, my identity outside the group or situation
I feel powerless, that I have no control
Sometimes I get triggered and have flashbacks (feeling stuck in a memory)
I am afraid someone will come after me. I feel watched.
I have difficulty talking about what happened or making sense of my experience
I feel depressed and find it difficult to function
I feel very angry. There is so much rage inside.
I have a hard time connecting to my emotions
I feel a sense of grief and loss
I question my reasoning, how I make decisions
I feel compelled to do certain things and find it hard to stop myself
I put myself down
I miss feeling chosen or special
It's all or nothing - I don't seem to find the middle ground
I feel like I have no future without them
I still think in us-versus-them terms, who is the enemy now?
I look for absolute truth and instant solutions to my troubles
I cannot let go of people, even when they hurt me or are toxic
I daydream or just drift off, disconnect from my feelings or where I am
I cannot feel my body
I feel overwhelmed by my emotions, like I am drowning
I feel like I have to be productive all the time, have difficulty relaxing
I flinch when someone is loud or yells
I don't feel safe
I feel stuck because I was not allowed to continue my education
Which one of the following areas where influenced by the rules of the group or relationship? (Check all that apply) *
Required
In what ways do you feel like you were manipulated in the group or by an individual? (Check all that apply) *
Required
Are any of these currently impacting your life? (Check all that apply) *
Required
If you were in a group what kind of group was it? (Check all that apply) *
Required
If you are comfortable, share a few sentences about what you experienced and how it has affected you.
I recognize Stronger After is a form of coaching and is in no way to be construed or substituted as psychological counseling or any other type of therapy or medical advice. *
Required
Email *
Please re-enter your email *
Thank you! We will reach out to you within 1-2 weeks. If you do not hear from us, please do not hesitate to contact us at coaching.stronger.after@gmail.com.
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