Daring Way Women’s Workshop - WEST DES MOINES CENTER FOR PSYCHOTHERAPY

Demographic Information

Name *

First

Middle

Last

Date Of Birth

Gender

Ethnicity

Relationship Status

Married
Single
Separated
Divorced
Partnered
Dating
Widowed
Other

Employer

Currently Employed

Occupation

Home Address

City

Zip

Mobile Number

Work Number

Which phone number is your preferred contact?

Mobile
Work

Email *

Would you like to be notified of future Workshops?

Emergency Contact Information

Please provide as much information below so i can easily reach your emergency contact if needed

Name *

First

Last

Relationship

Mobile Number (copy)

Work Number (copy)

Referral Information

Were you referred to us?

If yes, who referred you?

If no, how did you hear about us?

Workshop Interest

Please answer all of the following questions and indicate if they aren’t applicable to you

1. What sparked your interest in participating in this workshop?

2. What do you hope to accomplish as a result of your participation in this workshop?

3. Have you previously participated in a group?

How would you respond if someone dominated the discussion?

How may you respond if someone never particiapted?

Mental Health History With Informed Consent

Your answers to the following questions will help us assess your needs. Please answer to the best of your ability.

1. Are you seeing, or have you ever seen a mental health provider?

If yes, when was that and for what pupose?

2. Do you have a therapist that you can work with if something came up that would require attention?

If not, would you like a referral to a therapist?

3. Are you in recovery from a substance or alcohol abuse? If so, how long have you been sober and what kind of treatment are you receiving at this time?

4. Do you have a history of eating disorders or disordered eating? If so, please provide information on the support and treatment that you received.

5. Have you experienced distressing life events (i.e., trauma, loss, etc.) that have significantly impacted your ability to function or your quality of life? How have you addressed these issues?

Single Item

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