Renewal Group Intake
Renewal Groups aim to transform the whole person by encouraging growth in knowledge and skills.
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 *
Required
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) *
Submit
Never submit passwords through Google Forms.
This form was created inside of Cumberland Community Church. Report Abuse