Group intake Form - Effect Behavioral Health Solutions Inc.

Name

First

Last

Email

Phone

Group Name

Number of Participants

Group Type

Preferred Date/Time

Date

Time

Group Goals / Notes

Date of Birth

Address

Address Line 1

Address Line 2

City

State

Zip Code

What brings you to therapy at this time?

What specific concerns would you like help with?

How long have you been experiencing these issues?

What symptoms are you experiencing? (Select all that apply)

How comfortable are you sharing personal experiences with others?

Not comfortable
Somewhat comfortable
Comfortable
Very comfortable

Do you feel comfortable listening to others discuss their struggles?

Not comfortable
Somewhat comfortable
Comfortable
Very comfortable

of from this

What concerns do you have about participating in group therapy?

Why are you interested in joining a therapy group?

What do you hope to gain from group therapy?

Have you participated in group therapy before?

Yes
No

If yes, please describe your experience.

Have you previously attended therapy?

Yes
No

Have you been diagnosed with a mental health condition?

Yes
No

Are you currently seeing another therapist or psychiatrist?

Yes
No

Are you currently taking medication for mental health concerns?

Yes
No

Have you had thoughts of harming yourself?

Yes
No

Have you had thoughts of harming others?

Yes
No

Have you ever attempted suicide?

Yes
No

Do you feel safe participating in a group environment?

Yes
No

Do you currently use alcohol or drugs?

Yes
No

Has substance use affected your mental health or relationship?

Yes
No

Client Signature

Clear Signature

EBHS Group Intake Form