Rising Strong: The Daring Way™ Intake Form
Questionnaire for Rising Strong: The Daring Way™, adapted with love from "Daring in Des Moines". PLEASE ALLOW YOURSELF AT LEAST THIRTY MINUTES to fill out this form. Thank you for submitting the form below. Please complete the sections to provide the confidential information needed to complete your registration. Your participation in the workshop/group will be confirmed upon the receipt of your non-refundable deposit, along with the submission of the Rising Strong: The Daring Way™ Questionnaire. This may be electronically submitted or mailed to us to Jessica Foley, 36 Beaver Street, Waltham, MA 02453-7006.
Email address *
Name (First & Last) *
Your answer
Address *
Your answer
Phone Number *
Your answer
Email Address *
Your answer
Emergency Contact, Relationship, & Phone Number *
Your answer
Which Retreat Weekend Would You Like? *
Your answer
How did you hear about our workshops? *
Your answer
Would you like to be included in our email list about future events? *
A word about this questionnaire:
Your guides for these workshops are Jessica Foley & Andrea St. George. Both are Certified Daring Way Facilitators and Consultants with The Daring Way™. They have completed an extensive training process with Dr. Brene’ Brown and her team to understand and teach this curriculum. Your willingness to answer the questions below will help us best assess your readiness for a group experience such as this. Thank you so much for your cooperation in answering these questions:
Have you ever seen a mental health professional (Psychiatrist, psychologist, marriage and family therapist, social worker, counselor?) *
If yes, when? Please briefly list the reasons and outcomes. *
Your answer
Do you have a therapist you could work with if something came up in this workshop requiring individual/couple attention? *
If not, would you be open to referrals to therapists? *
Are you currently taking any medication for mental health issues? *
If yes, please explain: *
Your answer
Are you in recovery from substance or alcohol abuse? If so, how long have you been sober? Please provide a brief description of the treatment and support you receive for maintaining sobriety? *
Your answer
Do you have a history of eating disorders or disordered eating? If so, please provide information on the support and treatment you are/have received: *
Your answer
Have you experienced distressing life events (trauma, loss, etc.) that have significantly impacted your functioning and quality of life? If so, please provide information about how you have addressed these issues. *
Your answer
What sparked your interest in our workshops? *
Your answer
What would you like to accomplish as a result of attending our workshop? *
Your answer
What previous experience have you had, if any, with group therapy or a support group? Please list names & dates of any groups:
Your answer
How were they helpful? What difficulties did you have, if any?
Your answer
What concerns, if any, do you have about participating in a group experience? *
Your answer
How would you respond as a group member if someone in the group dominated the discussion? *
Your answer
How would your respond as a group member if someone never participated in the group discussion? *
Your answer
What else would you like us to know about you? *
Your answer
What Brene Brown books, online classes, or previous groups have you experienced? *
Your answer
Thank you so much for providing this information! We will review the information you provided and follow up with you to schedule your brief phone interview. For questions or more information you may contact us at: jfoley@jessicafoley.com
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.