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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?
*
Your answer
What is your phone number?
*
Your answer
What is your email address?
*
Your answer
How do you prefer to be contacted?
*
phonecall
text message
email
Required
Have you ever done a support or therapy group before?
Yes
No
Clear selection
Do you have a therapist?
Yes- Individual therapist
Yes- couples therapist
No
Not now but I have seen a therapist in the past
How long have you been dealing with betrayal trauma?
*
Your answer
Please give a brief description of what has happened and current concerns/status of relationship.
*
Your answer
What themes/topics are you most interested in learning about?
Your answer
Do you have supportive friend/family/faith community relationships who are aware of what is going on?
Yes
No
Clear selection
Do you have any fears or concerns about attending group?
Your answer
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