Welcome!We are thrilled for you to join us on this adventure on Lopez Island. Please fill out the questionnaire below so we can be well prepared. Name * First Name Last Name Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contact Name * First Name Last Name Phone * (###) ### #### How did you hear about us? Would you like to be included in my e-mail list about future events? * Yes please! No thank you Your willingness to answer the questions below will help me best assess your readiness for this group experience. Have you ever seen a mental health professional (Psychiatrist, psychologist, marriage and family therapist, social worker, counselor?) Yes No If yes, when? Briefly describe the outcomes. Do you have a therapist you could work with if something came up in this workshop requiring individual/couple attention? Yes No If not, would you like referrals to therapists? Yes please No thank you Are you currently taking any medication for mental health issues? 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? 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. 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. What sparked your interest in the workshop? What would you like to accomplish as a result of attending the workshop? What previous experience have you had, if any, with group therapy or a support group? Please list dates and the name of the group. How were they helpful? What difficulties did you have, if any? What concerns, if any, do you have about participating in a group experience? How would you respond as a group member if someone in the group dominated the discussion? How would you respond as a group member if someone never participated in the group discussion? What else would you like us to know about you? Thank you so much for providing this information! I will review the information you provided and follow up with you to confirm your registration. By checking the box below you are consenting to have your registration information seen by Jennifer and Dianne. All information will remain confidential and will only be used for clerical reasons. Yes I have read and agree Thank you!
