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Email
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Home Phone
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Preferred Contact Method
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Email
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How did you hear about GROWTH?
How did you hear about GROWTH?
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Professional Support (Therapist / Life Coach / Interventionist/ Education Specialist / Faith Leader
Therapeutic Program
Conference/Live Event
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Which program(s) are you interested in?
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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.
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When are you interested in attending GROWTH?
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What are your goals for your time at GROWTH?
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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
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Do you have a mental health diagnosis?
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Yes
No
What is your mental health diagnosis?
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Are you taking medication for your mental health diagnosis? If so, please list.
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Are you currently experiencing any suicidal ideation / attempts?
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Yes
No
Have you experienced any suicidal ideation / attempts in the past?
*
Yes
No
Please explain your suicidal ideation / attempts
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Have you had any recent hospitalizations?
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Yes
No
Please explain your recent hospitalizations.
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Do you live or have you traveled outside the U.S. in the last two weeks?
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Yes
No
Please specify which country(s).
Are you experiencing any flu-like or respiratory symptoms?
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Yes
No
Please explain.
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