Mending The Soul Interest Form

Entry Entry

First Name

Last Name

Gender

Address

Home Phone

Cell Phone

Work Phone

Marital Status

Level of Education

Please briefly describe your story of pain or abuse and why you are interested in attending a small group for healing.

How would you describe your personal health? Do you have any health issues that may prevent your from attending group regularly?

Are you currently taking any prescription drugs?

The effects of abuse sometimes lead to other struggles that we are not equipped to handle in depth during small group meetings. Are you struggling with any behaviors with which you may need extra support outside of the group, such as recreational drug or alcohol use, an eating disorder, workaholism, sexual addiction, internet addiction, spending addiction, or codependency? Are you already receiving support for any of these struggles? Please explain.

If you are unsure if you are drug or alcohol dependent or struggling with an eating disorder, just write that you are unsure and the facilitator will discuss this with you.

Are you currently in an abusive relationship?

Are you in a time of great stress or important transition in your life?

Would you consider yourself to be depressed?

Have you ever had any serious thoughts about committing suicide or made a suicide plan or attempt? If so, please describe how and when.

Have you been diagnosed with a mental illness, including Obsessive Compulsive Disorder (ODC) or Bi-Polar Disorder (BPD), also known as Manic Depressive Disorder? If so, how is it being treated? Do you see any reason why this condition would interfere with your ability to concentrate on the workbook material required for this group?

Is there anything else in your life that may make it difficult for you to concentrate that we should be aware of? (Personal habits or mannerisms, ADD or ADHD, etc.)

Have you ever received counseling?

I have received professional counseling I have received pastoral counseling I have received lay counseling I have never received counseling

Check all that apply

Describe your religious upbringing

Please note that the group is open to those from all religious backgrounds.
Abuse wounds the spirit and soul.

What is your perception of God?

Do you have a church home?

Where would you like to attend Mending the Soul?

Submit