Group Therapy Intake FormPlease fill out this form to help us understand your needs for group therapy. Name * First Name Last Name Date of Birth MM DD YYYY Phone * (###) ### #### Email * How did you hear about our group therapy? * Referral (Friend/Family) Therapist Referral Online Search Social Media Flyer/Brochure Other What are your primary reasons for seeking group therapy at this time? (Select all that apply) * Coping with anxiety Managing depression Grief and loss Relationship issues Stress management Personal growth Building social skills Other What do you hope to gain from participating in group therapy? * On a scale of 1 to 10, how comfortable are you sharing personal experiences in a group setting? * 1 = Not comfortable at all 10 = Extremely comfortable 1 2 3 4 5 6 7 8 9 10 Please list any previous experience you have had with therapy (individual, group, etc.) * Do you have any current mental health diagnoses? (Optional) Is there anything else you would like us to know that would help us support you in group therapy? * Thank you for completing the Group Therapy Intake Form. We’ve received your responses and will be in touch soon with the next steps.
