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Write your name or initials, whether you are participating through a clinic or inquiring independently, preferred method of contacting you, and briefly describe what change you would like therapy to help with.
Intake Questionnaire for Treatment Supported Rite of Passage
What kind of support do you need? Check all that apply
I have gotten through a major change or crisis, but now either something about it is haunting me or I feel I no longer know who I am
I am in a crisis, I am having to deal with a huge amount of change and I mostly need support to keep my head and get through it all.
I don't know why I have symptoms, I have had them for a long time and I finally want to learn about them and what I can do to change them
I need help to deal with other people; I am under a lot of stress that is completely outside of my control
I feel like I don't know who I am, have lost a sense of who I am, or I want to change who I am, and I want help moving into a stronger identity
I feel like I am out of control and I need help to gain some kind of control
I feel disoriented about reality and I need help with an ongoing reality check
I am not in a crisis, I just feel kind of empty and disconnected and I'd like to get back to living my life
I have had therapy before and resolved issues, now a new problem has arisen and I need help coping
I have always felt that I have been running away from an issue, and now something has happened that makes me feel that it is the right time to deal with it.
Which of the following describes you best?
I do not need to change; other people do
I need to change, but I'm not sure what
I know what I need to change, but I don't know how
I can't change
I am actively trying to change
I have changed, but it is hard to keep it up
I am considering changing, but I'm not sure I am ready
Which of the following modalities interests you? Check all that apply.
I would like medication to help me change
I would like support controlling my thoughts and feelings to help me change
I would like to do entirely telehealth
I would like to do a mixture of telehealth and in-person sessions
I would like support with self-advocacy and boundary setting in my relationships to get better support
I am interested in nature-based activities to explore nonverbal insights, mindfulness, and empowerment
I am interested in art-based activities to explore nonverbal insights, mindfulness, and empowerment
I would like to improve my coping strategies in order to change
I would like to improve my ability to find balance in my life
I would like someone to listen to me and help me better understand my symptoms
I would like to explore my story and my identity and how it relates to my current symptoms and stressors
I am interested in mindfulness techniques and how they can help me
I am interested in group support
I am interested in an experience (such as a retreat or rite of passage workshop) that puts me in a totally different context in order to learn something new about myself
I am interested in marking a change in my life using symbols
Availability for Experiential Workshops or Retreats
I am only interested in regular outpatient therapy sessions
I would like to do retreats or workshops
I am interested in retreats or workshops but finances are an obstacle
I am interested in retreats or workshops but my availability is an obstacle because I have work/family responsibilities
I am interested in retreats or workshops but I would prefer to do them one-on-one versus in a group
I have health concerns that may be an obstacle to outdoor or retreat activities
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