Group Counseling Intake / Survey

Group Therapy Intake / Survey

Are you interested in group counseling? Fill out this Intake/Survey and your preferences will be sent directly to More MH Counseling
Once a sufficient amount of group members (4 minimum) are a good match, you will be contacted to confirm participation.

Group members must commit to 10 weekly 45 minute sessions for $10.00 per session. Some insurance companies may cover this cost.
Location: North Providence, RI
Dates: Weekday evenings and Saturdays available

* Indicates required field

Name: *

Address *

Gender *

Male Female

Date (XX/XX/XXXX) *

Age *

Date of Birth (XX/XX/XX) *

Employer *

Insurance Company *

Position *

Insurance Plan *

Full Time / Part-Time *

Policy Number *

Group Location *

North Providence, RI Cataumet, MA

Other: *

Have you ever participated in group therapy? *

Yes No

Briefly Describe *

Do you have any preferences or barriers surrounding group therapy? (gender specific group only, age preferences, availability, transportation issues) *

Why are you seeking group counseling? *

Are you interested in individual counseling? *

Yes No

What are your treatment goals? *

Mental Health History

Do you have a current therapist? *

Yes No

Therapist contact information (Name, address, phone, frequency) *

Do you have a mental health diagnosis? *

Yes No

Describe your mental health history (current/past symptoms or treatment) *

Current psychiatric medication? *

Yes No

Current and history of psychiatric medication (med, dosage, prescriber) *

Current disruption in functioning? *

Yes No

Have you ever self-injured or attempted suicide in the past? *

Yes No

History of psychiatric inpatient admissions? *

Yes No

Disruptions in your ability to go to work, care for your children, self-care, etc. *

Briefly describe *

Briefly describe Reason, where, when *

Current or history of substance abuse? *

Yes No

Do you have interfering Medical Issues? *

Yes No

Family psychiatric history? *

Yes No

Describe your history - Substance, Quantity, Frequency, Overdose history *

Describe medical issues/medications/accommodations needed *

Describe *

Primary Care physician *

Emergency Contact *

Other information you would like More MH Counseling to know *

How did you hear about Group Counseling? *

Internet Search Advertisement Friend

Other *

I agree to receiving marketing and promotional materials

Submit

Group Therapy Intake / Survey

Are you interested in group counseling? Fill out this Intake/Survey and your preferences will be sent directly to More MH CounselingOnce a sufficient amount of group members (4 minimum) are a good match, you will be contacted to confirm participation.

Mental Health History

​More MH Counseling, LLCCopyright 2022

Are you interested in group counseling? Fill out this Intake/Survey and your preferences will be sent directly to More MH Counseling
Once a sufficient amount of group members (4 minimum) are a good match, you will be contacted to confirm participation.

More MH Counseling, LLC
Copyright 2022