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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)

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

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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:

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.
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