Teen Support Group Question Title * 1. What is your first name? w 0 Question Title * 2. At what email address would you like to be contacted? w 0 Question Title * 3. Do you have a phone number to contact you? If so, what is your number? w 0 Question Title * 4. Are your parents aware of the support group? w 0 Yes No Question Title * 5. Have your parents given you permission to attend the support group? w 0 Yes No Question Title * 6. Are you currently in counseling? w 0 Yes No Question Title * 7. Have you been seen by a crisis worker or had a psychiatric hospitalization within the last year? w 0 Yes No Question Title * 8. Have you ever been involved or currently in another group? w 0 Yes No Question Title * 9. Are you comfortable with having peers you know or from your school attend the group? w 0 Yes No Question Title * 10. What do you already have in place for a support system? w 0 Question Title * 11. What do you hope to get from this group? w 0 Question Title * 12. What would help you feel comfortable and safe in-group? w 0 Question Title * 13. What do you do when you are stressed, upset, angry, sad, etc.? w 0 Question Title * 14. Do you understand what confidentiality is and how vital it is in this situation? w 0 Yes No Question Title * 15. Are you able to commit to attending the group weekly? w 0 Yes No Question Title * 16. If you cannot commit regularly, what are your barriers to coming every week? w 0 Transportation Extra-curricular Activities Work Other Question Title * 17. There is an expectation that you will not use alcohol or drugs at least 12 hours before the start of each meeting. Are you able to make this commitment to the group? w 0 Yes No Not sure Question Title * 18. Please check all topics you would like to discuss and receive information about: w 0 Healthy and Unhealthy Relationships Self-Injury & Cutting/Harmful Behaviors Coping skills Setting Boundaries Overcoming Trauma Depression Impact of Sexual Assault Self-Esteem Healthy Sexual Relationships Rebuilding Trust Shame and Guilt Managing Anger Eating Disorders Sex Trafficking Interpersonal Relationships with Communication Other (please specify) Question Title * 19. Describe what you are least wanting to do or talk about during this group. w 0 Question Title * 20. What do you like about yourself? w 0 Question Title * 21. What do you want to change about yourself or work on? w 0 Question Title * 22. Describe yourself in five words…. w 0 Done
