rediscover the things that bring you joy

Name *

First Name

Last Name

Phone

(###)

###

####

What is your primary reason for seeking group therapy? *

a) Anxiety

b) Depression

c) Relationship issues

d) Stress management

e) Grief and loss

f) Other (please specify)

Have you ever participated in group therapy before?

Yes

No

How comfortable are you with sharing personal information in a group setting? *

a) Very comfortable

b) Somewhat comfortable

c) Neutral

d) Somewhat uncomfortable

e) Very uncomfortable

How often do you experience feelings of isolation or loneliness? *

a) Always

b) Often

c) Sometimes

d) Rarely

e) Never

What is your current level of support from family and friends? *

a) Very supportive

b) Somewhat supportive

c) Neutral

d) Somewhat unsupportive

e) Very unsupportive

How would you rate your overall mental health at the moment? *

a) Excellent

b) Good c) Fair d) Poor e) Very poor

b) Good

c) Fair

d) Poor

e) Very poor

Do you have any specific goals you hope to achieve through group therapy? *

a) Improve communication skills

b) Gain support and understanding

c) Learn coping strategies d) c) Build self-esteem

e) Other (please specify)

How do you typically cope with stress or difficult emotions? *

a) Talking to friends/family

b) Physical activity/exercise

c) Engaging in hobbies

d) Seeking professional help

e) Other (please specify)

Are you currently receiving any other form of mental health treatment (e.g., individual therapy, medication)?

Yes

No