Intake Questionnaire

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* 1. How did you become involved in the group:

born into

parents joined when I was a child / teenager

I was recruited as an adult

I was recruited as a minor

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* 2. I am currently:

still in the group

I have left

If you have left, how long ago?

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* 3. How did you leave?

I left on my own

Someone else left and I had to follow

I was forced to leave

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* 4. Do you experience the following and how often does it bother you? (check each column, as it applies)

	never	sometimes	often	always	not sure what the question means
Thoughts keep circling in my head, I can't make them stop	Thoughts keep circling in my head, I can't make them stop never	Thoughts keep circling in my head, I can't make them stop sometimes	Thoughts keep circling in my head, I can't make them stop often	Thoughts keep circling in my head, I can't make them stop always	Thoughts keep circling in my head, I can't make them stop not sure what the question means
I don't think I'm worthy of love	I don't think I'm worthy of love never	I don't think I'm worthy of love sometimes	I don't think I'm worthy of love often	I don't think I'm worthy of love always	I don't think I'm worthy of love not sure what the question means
I have nightmares	I have nightmares never	I have nightmares sometimes	I have nightmares often	I have nightmares always	I have nightmares not sure what the question means
Fears about the world ending, hell, karma or other punishment	Fears about the world ending, hell, karma or other punishment never	Fears about the world ending, hell, karma or other punishment sometimes	Fears about the world ending, hell, karma or other punishment often	Fears about the world ending, hell, karma or other punishment always	Fears about the world ending, hell, karma or other punishment not sure what the question means
Fear of making mistakes	Fear of making mistakes never	Fear of making mistakes sometimes	Fear of making mistakes often	Fear of making mistakes always	Fear of making mistakes not sure what the question means
Shame for having participated	Shame for having participated never	Shame for having participated sometimes	Shame for having participated often	Shame for having participated always	Shame for having participated not sure what the question means
Difficulty making decisions	Difficulty making decisions never	Difficulty making decisions sometimes	Difficulty making decisions often	Difficulty making decisions always	Difficulty making decisions not sure what the question means
Sense of dread	Sense of dread never	Sense of dread sometimes	Sense of dread often	Sense of dread always	Sense of dread not sure what the question means
Anxiety and panic	Anxiety and panic never	Anxiety and panic sometimes	Anxiety and panic often	Anxiety and panic always	Anxiety and panic not sure what the question means
Guilt for having left the group	Guilt for having left the group never	Guilt for having left the group sometimes	Guilt for having left the group often	Guilt for having left the group always	Guilt for having left the group not sure what the question means
Guilt for having left people behind	Guilt for having left people behind never	Guilt for having left people behind sometimes	Guilt for having left people behind often	Guilt for having left people behind always	Guilt for having left people behind not sure what the question means
Guilt for living / enjoying life	Guilt for living / enjoying life never	Guilt for living / enjoying life sometimes	Guilt for living / enjoying life often	Guilt for living / enjoying life always	Guilt for living / enjoying life not sure what the question means
An internalized voice criticizing or policing me	An internalized voice criticizing or policing me never	An internalized voice criticizing or policing me sometimes	An internalized voice criticizing or policing me often	An internalized voice criticizing or policing me always	An internalized voice criticizing or policing me not sure what the question means
Feeling alone, missing community	Feeling alone, missing community never	Feeling alone, missing community sometimes	Feeling alone, missing community often	Feeling alone, missing community always	Feeling alone, missing community not sure what the question means
Strong beliefs and inner convictions that I didn't choose	Strong beliefs and inner convictions that I didn't choose never	Strong beliefs and inner convictions that I didn't choose sometimes	Strong beliefs and inner convictions that I didn't choose often	Strong beliefs and inner convictions that I didn't choose always	Strong beliefs and inner convictions that I didn't choose not sure what the question means
Feeling responsible for others and their needs	Feeling responsible for others and their needs never	Feeling responsible for others and their needs sometimes	Feeling responsible for others and their needs often	Feeling responsible for others and their needs always	Feeling responsible for others and their needs not sure what the question means
Lack of boundaries, not sure when someone is violating mine	Lack of boundaries, not sure when someone is violating mine never	Lack of boundaries, not sure when someone is violating mine sometimes	Lack of boundaries, not sure when someone is violating mine often	Lack of boundaries, not sure when someone is violating mine always	Lack of boundaries, not sure when someone is violating mine not sure what the question means
Difficulty connecting with other people	Difficulty connecting with other people never	Difficulty connecting with other people sometimes	Difficulty connecting with other people often	Difficulty connecting with other people always	Difficulty connecting with other people not sure what the question means
Difficulty with sexuality and physical closeness	Difficulty with sexuality and physical closeness never	Difficulty with sexuality and physical closeness sometimes	Difficulty with sexuality and physical closeness often	Difficulty with sexuality and physical closeness always	Difficulty with sexuality and physical closeness not sure what the question means
Difficulty trusting others	Difficulty trusting others never	Difficulty trusting others sometimes	Difficulty trusting others often	Difficulty trusting others always	Difficulty trusting others not sure what the question means
Difficulty finding a job or being able to keep it	Difficulty finding a job or being able to keep it never	Difficulty finding a job or being able to keep it sometimes	Difficulty finding a job or being able to keep it often	Difficulty finding a job or being able to keep it always	Difficulty finding a job or being able to keep it not sure what the question means
Issues with authority at the workplace or elsewhere	Issues with authority at the workplace or elsewhere never	Issues with authority at the workplace or elsewhere sometimes	Issues with authority at the workplace or elsewhere often	Issues with authority at the workplace or elsewhere always	Issues with authority at the workplace or elsewhere not sure what the question means
Difficulty speaking up and not letting others take advantage of me	Difficulty speaking up and not letting others take advantage of me never	Difficulty speaking up and not letting others take advantage of me sometimes	Difficulty speaking up and not letting others take advantage of me often	Difficulty speaking up and not letting others take advantage of me always	Difficulty speaking up and not letting others take advantage of me not sure what the question means
Suicidal thoughts	Suicidal thoughts never	Suicidal thoughts sometimes	Suicidal thoughts often	Suicidal thoughts always	Suicidal thoughts not sure what the question means
Exhaustion	Exhaustion never	Exhaustion sometimes	Exhaustion often	Exhaustion always	Exhaustion not sure what the question means
Lack of education	Lack of education never	Lack of education sometimes	Lack of education often	Lack of education always	Lack of education not sure what the question means
Stress from family still in the group	Stress from family still in the group never	Stress from family still in the group sometimes	Stress from family still in the group often	Stress from family still in the group always	Stress from family still in the group not sure what the question means
No sense of who I am, my identity outside of the group	No sense of who I am, my identity outside of the group never	No sense of who I am, my identity outside of the group sometimes	No sense of who I am, my identity outside of the group often	No sense of who I am, my identity outside of the group always	No sense of who I am, my identity outside of the group not sure what the question means
Feeling powerless, lack of control	Feeling powerless, lack of control never	Feeling powerless, lack of control sometimes	Feeling powerless, lack of control often	Feeling powerless, lack of control always	Feeling powerless, lack of control not sure what the question means
Something triggers me and I have flashbacks	Something triggers me and I have flashbacks never	Something triggers me and I have flashbacks sometimes	Something triggers me and I have flashbacks often	Something triggers me and I have flashbacks always	Something triggers me and I have flashbacks not sure what the question means
I'm afraid that someone will come after me / I feel watched	I'm afraid that someone will come after me / I feel watched never	I'm afraid that someone will come after me / I feel watched sometimes	I'm afraid that someone will come after me / I feel watched often	I'm afraid that someone will come after me / I feel watched always	I'm afraid that someone will come after me / I feel watched not sure what the question means
Difficulty talking about what happened / making sense of my experience	Difficulty talking about what happened / making sense of my experience never	Difficulty talking about what happened / making sense of my experience sometimes	Difficulty talking about what happened / making sense of my experience often	Difficulty talking about what happened / making sense of my experience always	Difficulty talking about what happened / making sense of my experience not sure what the question means
I feel depressed and find it difficult to function	I feel depressed and find it difficult to function never	I feel depressed and find it difficult to function sometimes	I feel depressed and find it difficult to function often	I feel depressed and find it difficult to function always	I feel depressed and find it difficult to function not sure what the question means
I am very angry, there's so much rage	I am very angry, there's so much rage never	I am very angry, there's so much rage sometimes	I am very angry, there's so much rage often	I am very angry, there's so much rage always	I am very angry, there's so much rage not sure what the question means
I have a hard time connecting to my emotions	I have a hard time connecting to my emotions never	I have a hard time connecting to my emotions sometimes	I have a hard time connecting to my emotions often	I have a hard time connecting to my emotions always	I have a hard time connecting to my emotions not sure what the question means
Sense of grief and loss	Sense of grief and loss never	Sense of grief and loss sometimes	Sense of grief and loss often	Sense of grief and loss always	Sense of grief and loss not sure what the question means
I question my reasoning, how I make decisions	I question my reasoning, how I make decisions never	I question my reasoning, how I make decisions sometimes	I question my reasoning, how I make decisions often	I question my reasoning, how I make decisions always	I question my reasoning, how I make decisions not sure what the question means
I feel compelled to do certain actions, I can't stop myself	I feel compelled to do certain actions, I can't stop myself never	I feel compelled to do certain actions, I can't stop myself sometimes	I feel compelled to do certain actions, I can't stop myself often	I feel compelled to do certain actions, I can't stop myself always	I feel compelled to do certain actions, I can't stop myself not sure what the question means
I put myself down	I put myself down never	I put myself down sometimes	I put myself down often	I put myself down always	I put myself down not sure what the question means
I miss feeling chosen and special	I miss feeling chosen and special never	I miss feeling chosen and special sometimes	I miss feeling chosen and special often	I miss feeling chosen and special always	I miss feeling chosen and special not sure what the question means
It's all or nothing - I don't seem to find middle ground	It's all or nothing - I don't seem to find middle ground never	It's all or nothing - I don't seem to find middle ground sometimes	It's all or nothing - I don't seem to find middle ground often	It's all or nothing - I don't seem to find middle ground always	It's all or nothing - I don't seem to find middle ground not sure what the question means
I feel like I have no future without the group	I feel like I have no future without the group never	I feel like I have no future without the group sometimes	I feel like I have no future without the group often	I feel like I have no future without the group always	I feel like I have no future without the group not sure what the question means
I still think in us-versus-them terms, who is the enemy now?	I still think in us-versus-them terms, who is the enemy now? never	I still think in us-versus-them terms, who is the enemy now? sometimes	I still think in us-versus-them terms, who is the enemy now? often	I still think in us-versus-them terms, who is the enemy now? always	I still think in us-versus-them terms, who is the enemy now? not sure what the question means
I look for absolute truth and instant solutions for my troubles	I look for absolute truth and instant solutions for my troubles never	I look for absolute truth and instant solutions for my troubles sometimes	I look for absolute truth and instant solutions for my troubles often	I look for absolute truth and instant solutions for my troubles always	I look for absolute truth and instant solutions for my troubles not sure what the question means
I cannot let go of people, even when they hurt me or are toxic	I cannot let go of people, even when they hurt me or are toxic never	I cannot let go of people, even when they hurt me or are toxic sometimes	I cannot let go of people, even when they hurt me or are toxic often	I cannot let go of people, even when they hurt me or are toxic always	I cannot let go of people, even when they hurt me or are toxic not sure what the question means
I daydream or just drift off, disconnect from my feelings	I daydream or just drift off, disconnect from my feelings never	I daydream or just drift off, disconnect from my feelings sometimes	I daydream or just drift off, disconnect from my feelings often	I daydream or just drift off, disconnect from my feelings always	I daydream or just drift off, disconnect from my feelings not sure what the question means
I cannot feel my body	I cannot feel my body never	I cannot feel my body sometimes	I cannot feel my body often	I cannot feel my body always	I cannot feel my body not sure what the question means
I feel overwhelmed by my emotions, like I am drowning	I feel overwhelmed by my emotions, like I am drowning never	I feel overwhelmed by my emotions, like I am drowning sometimes	I feel overwhelmed by my emotions, like I am drowning often	I feel overwhelmed by my emotions, like I am drowning always	I feel overwhelmed by my emotions, like I am drowning not sure what the question means
I feel like I have to be productive all the time, difficulty relaxing	I feel like I have to be productive all the time, difficulty relaxing never	I feel like I have to be productive all the time, difficulty relaxing sometimes	I feel like I have to be productive all the time, difficulty relaxing often	I feel like I have to be productive all the time, difficulty relaxing always	I feel like I have to be productive all the time, difficulty relaxing not sure what the question means
I flinch when someone is loud or yells	I flinch when someone is loud or yells never	I flinch when someone is loud or yells sometimes	I flinch when someone is loud or yells often	I flinch when someone is loud or yells always	I flinch when someone is loud or yells not sure what the question means
I don't feel safe	I don't feel safe never	I don't feel safe sometimes	I don't feel safe often	I don't feel safe always	I don't feel safe not sure what the question means

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* 5. Which types of abuse would you say you've experienced? (check all that apply)

verbal

emotional

sexual

physical

neglect

mind-games / gaslighting

none

Other (please specify)

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* 6. Did the group have many rules or influenced the following areas?
(check all that apply)

behavior

finances

information

emotions

thoughts

sexuality / birth control

sexual identity

work

free time

creativity / hobbies

diet

health care

pets

education

reading

entertainment

partner choice

parenting

vacation

none

Other (please specify)

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* 7. Do you feel like you were manipulated in the group? In what ways? (check all that apply)

fears

guilt

mind-games / gaslighting

dependency

promises

threats

punishment

sense of responsibility

through family / kids

isolation

lack of sleep

lack of privacy

lack of outside resources

not at all

Other (please specify)

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* 8. Are any of these currently impacting your life? (check all that apply)

homelessness

financial difficulty

mental health problems

lack of education

lack of employment

physical health problems

no identification documents

lack of support system

difficulty finding therapist

not at all

Other (please specify)

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* 9. What background did the group have? (check all that apply)

Christian

Judaeic

Islamic

satanic

therapeutic

alternative medicine

new age

Buddhist

political

multi-marketing

personal development

conspiracy

white supremacist

sex trade

human trafficking

Other (please specify)

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* 10. In which system / environment did you experience manipulation or abuse? (check all that apply)

group

family

romantic relationship

guru

work environment

online platform

If you're comfortable with it, share a few sentences about how each of these systems affected you and what you experienced during your involvement.

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* 11. Email:

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* 12. Please re-enter your email:

Your privacy: This Intake questionnaire will only be accessed by the EduCARE program director or the coaching supervisor in order to contact you. After you are paired up with your coach, only your coach will look at the intake questionnaire. Your name or email will not be shared with any third parties. We take your privacy seriously.

Intake Questionnaire

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* 1. How did you become involved in the group:

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* 2. I am currently:

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* 3. How did you leave?

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* 4. Do you experience the following and how often does it bother you? (check each column, as it applies)

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* 5. Which types of abuse would you say you've experienced? (check all that apply)

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* 6. Did the group have many rules or influenced the following areas? (check all that apply)

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* 7. Do you feel like you were manipulated in the group? In what ways? (check all that apply)

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* 8. Are any of these currently impacting your life? (check all that apply)

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* 9. What background did the group have? (check all that apply)

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* 10. In which system / environment did you experience manipulation or abuse? (check all that apply)

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* 11. Email:

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* 12. Please re-enter your email:

* 6. Did the group have many rules or influenced the following areas?
(check all that apply)