Renewal Group E - Mourning with Hope
All information on this form is strictly confidential. Your answers will help the group counselor understand the needs of the group and of each participant. It will also allow the staff to discern if this group experience is a good fit with your counseling needs at this moment. Lastly, it allows potential participants to review and to commit to the policies for group membership and the guidelines for group meetings.
Name: *
Your answer
Date of Birth: *
Your answer
Phone Number: *
Your answer
Email Address: *
Your answer
Gender: *
Marital Status: *
If you have children, please list how many and their ages:
Your answer
How did you hear about this Renewal Group? *
Your answer
Do you believe in God? *
What church do you currently attend? *
Write "None" if you do not currently attend one
Your answer
How much influence does your religion have on your day-to-day activity?
Your answer
Reasons for joining the Renewal Group
What concerns have led you to be interested in this Renewal Group? *
Please include how long you have had these concerns
Your answer
Tell us about the loss you experienced, including how recent the loss was and your relationship to your loved one. *
Please include how long you have had these concerns
Your answer
Please rate the severity of your present concerns on the following scale (Check one): *
What do you hope to get out of your group experience? *
Your answer
Do you have any previous support group or therapy group experience? *
If yes, please describe what kind, when and for how long. If no, write "None"
Your answer
What other sources of care and growth do you have?
Examples: Are you in a church small group? Are you receiving care from your church diaconate? Have you sought pastoral counsel regarding this group topic?
Your answer
Information about counseling experience and needs:
Note: this information is completely confidential and available only to the program director and group counselor.
Please check all that apply: *
Name of current counselor or therapist
Your answer
Contact information for current counselor:
Please give us the counselor's 1) phone number; and 2) email address
Your answer
Do you currently see a psychiatrist?
If you do, please give his your psychiatrist's name and contact info. If not, leave this blank.
Your answer
Do we have permission to contact your counselor and/or psychiatrist?
We would only make contact if we need feedback on whether this therapy group is a good fit for you right now.
Psychiatric medications currently taking, if any:
Your answer
Have you ever been hospitalized for psychiatric purposes? *
Have you attempted suicide in the last 12 months? *
If "yes" to either of the last two questions, please give us some details on the circumstances:
Your answer
Are there any other counseling-related issues you want us to know about?
Your answer
Group member commitments
Group Guidelines: *
I have read the "Group Guidelines" on the web page, and I commit to follow these guidelines during every meeting.
Confidentiality Commitment: *
In particular, I affirm that I have read the confidentiality rules in the "Group Guidelines" and I agree to hold the identity of each group member and all content discussed within the group in confidence. I also understand that breaking this commitment may entail dismissal from the group.
Full Cycle, Weekly Attendance: *
I commit to attend every group meeting weekly for the duration of the cycle, and to make any arrangements necessary to make participation in this group a top priority. If I cannot attend regularly, I will enroll in a future cycle, to make room for another participant who is able to more fully engage in the group.
Monthly Fee Payment: *
I have commit to payment of the first monthly payment online via the RCS website. I understand that the fee to maintain membership in this group is $200 per month to be paid at the beginning of the month (or the start of every 4 weeks). I understand we cannot allow for refunds, except in cases involving serious emergencies or long-term illness.
Signature: *
Please type your name as signature confirmation of all the above commitments. Thank you!
Your answer
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