Name *

Email address *

Age *

Phone Number *

Can we leave a confidential voice message? *

Are you inquiring for someone else (spouse, child, parent, etc)? If so, please list their name and relation to you.

Renewal Group I am Seeking *

Please tell us why you are seeking a group at this time. *In order to determine if we are able to meet your needs please be detailed. *

Have you ever been diagnosed by a therapist or psychiatrist? If so, what was/is your diagnosis? *

If you are interested in a group that we do not yet offer, what would that be? Or write N/A. *

How did you hear about Renewal Groups at Cumberland *

Are you also interested in individual counseling? *

Do you attend Cumberland Community Church? *

If you attend church but not Cumberland Community Church, where do you attend church? Or write N/A. *

What are your religious or spiritual beliefs? (Note: we work with all people regardless of beliefs or religious background.) *

Please list any major medical problems you currently have (or write n/a): *

Have you received counseling services from Cumberland Counseling before? *

Please describe your current reasons for seeking group counseling at this time. If there is a particular event which triggered your decision, please list this event: *

Have you ever strongly considered or attempted taking your own life? *

Are you considering taking your life currently? *

Is there anything else you’d like the clinician/group facilitator to know? (or write n/a) *