Beyond Broken Screening Form
Please answer the following questions to help me learn more about you. This will also assist with making sure that group is the best fit for you at this time in your betrayal trauma journey.  
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What is your first name and last initial? *
What is your phone number? *
What is your email address? *
How do you prefer to be contacted? *
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How did you learn about the group? *
Have you ever done a support or therapy group before?
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Do you have a therapist? 
How long have you been dealing with betrayal trauma? *
Please give a brief description of what has happened and current concerns/status of relationship.  *
What themes/topics are you most interested in learning about?
Do you have supportive friend/family/faith community relationships who are aware of what is going on?
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Do you have any fears or concerns about attending group?
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