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GET STARTED

TELL US MORE ABOUT YOU

Name *

First

Last

Email *

Home Phone *

Mobile Phone

Preferred Contact Method *

How did you hear about GROWTH?

How did you hear about GROWTH? *

Which program(s) are you interested in? *

HOST
Courageously Healing Trauma
Healthy Relationships
Living Whole
Faith Over Fear
Creative Dramatics
Small Steps
In-Touch
Sunlight and Candor
One-Day
Individual Intensive
Family Intensives
Milestones

Please enter the name(s) and age(s) of everyone attending. *

When are you interested in attending GROWTH? *

What are your goals for your time at GROWTH? *

Please give us a brief summary of your presenting issues. *

Have you/do you experience dissociation? *

i.e. Can you tell the story of your trauma without dissociating? Do you have any lapses in time/memory? If you do dissociate, are you able to ground yourself?

Are you experiencing any addictive or self-medicating behaviors? *

e.g. alcohol, drugs, food, sex, gambling, spending, work, exercise, etc.

Previous Treatment / Therapy Experience *

Do you have a mental health diagnosis? *

Yes
No

What is your mental health diagnosis? *

Are you taking medication for your mental health diagnosis? If so, please list. *

Are you currently experiencing any suicidal ideation / attempts? *

Yes
No

Have you experienced any suicidal ideation / attempts in the past? *

Yes
No

Please explain your suicidal ideation / attempts *

Have you had any recent hospitalizations? *

Yes
No

Please explain your recent hospitalizations. *

Do you live or have you traveled outside the U.S. in the last two weeks? *

Please specify which country(s).

Are you experiencing any flu-like or respiratory symptoms? *

Please explain.

G.R.O.W.T.H. Services

GROWTH was designed to ensure that high quality education and career opportunities are available to students and families across the nation.

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Contact Info

Address:1254 Central Road Baton Rouge, LA 70807
Phone:225-300-4943
Fax:225-300-4899
Email:CRobertson@growthla.orgOpens in your application

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