Childhood Trauma Recovery Group - Intake Form
Thank you for taking the time to fill out this questionnaire. Please answer every question to the best of your ability. Your responses will help me determine your readiness to join group therapy and will allow me to connect you with a group most suitable to you.

Please note: I am accepting new clients for groups this fall. Given the high level of interest in this work, I ask for your understanding that it will take some time for me to review your form. While I would like to get back to everyone who is interested, I am only able to follow up with those who I can find a good fit. 

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Email *
Please share your preferred name: *
Have you completed this form in the last 6 months?
Please select your availability for weekly group sessions:
I have difficulty connecting with myself or others.
Clear selection
How do you tend to support yourself currently when you are feeling overwhelmed?
Therapy has not been beneficial for me in the past.
Clear selection
I struggle with dissociation most days (feeling disconnected or outside of my body)
Clear selection
I am overwhelmed with stress most days.
Clear selection
I am looking for accelerated short-term change (under 1 year)
Clear selection
My problems are more situational vs. emotional/internal.
Clear selection
I do not know how my childhood has impacted me.
Clear selection
I have current/ongoing legal concerns
Clear selection
I currently have problems of safety (ie. domestic violence, family or personal crisis)
Clear selection
I am currently in a contentious separation or divorce.
Clear selection
I am seeking this model of therapy because it was suggested to me to do childhood trauma work and would otherwise not have considered this to be helpful.
Clear selection
I have attempted suicide in the last year.
Clear selection
I've been to the hospital as an inpatient or in a day program over the last year
Clear selection
What has helped you specifically so far? (ie. self help books, 12 step groups, medication, talk therapy, etc.) How did you notice that it was helpful?
What is the number one concern in your life right now?
Do you have one or more persons in your life that you can turn to in times of trouble?
Anything else you'd like to add or like me to know?
Thank you for completing this form. I'll contact you as soon as I can to schedule a consultation call if I find that there is a suitable group for you at this time. I appreciate your patience.

Warmly, 
Amanda
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