Help Her Heal Questionnaire

Please complete the sections below marked with a * to provide the confidential information needed to complete your registration. The rest of the questionnaire is optional, however, your willingness to complete it will help me know you better as you embark on this journey. Your participation in this group will be confirmed upon the receipt of payment for your first group along with the completion of this Help Her Heal questionnaire and consent form (found on the next page). Thank you and I look forward to seeing you!

Full Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number*

Area CodePhone Number

E-mail*

How did you hear about this workshop?

Would you like to be included on my email list about future events?*

Workshop Type Attending*

Your guide for this Help Her Heal Group is Judy Kelly. She is a Licensed Clinical Social Worker in the State of California and a Certified Sex Addiction Treatment Therapist. She has trained with Dr. Patrick Cranes and is a member of the International Institute of Trauma and Addiction Professionals (IITAP). Your willingness to answer the questions below will help her best to assess your readiness for a group experience such as this. Thank you so much for your cooperation in answering these questions:

Have you ever seen a mental health professional (Psychiatrist, psychologist, marriage and family therapist, social worker, counselor?)

Please briefly list the reasons and outcomes.

Do you have a therapist you could work with if something came up in this workshop requiring individual/couple attention?

Would you like referrals to therapists?

Are you currently taking any medication for mental health issues?

Please explain

Are you in recovery from substance or alcohol abuse? If so, how long have you been sober? Please provide a brief description of the treatment and support you receive for maintaining sobriety:

Do you have a history of eating disorders, sexual addiction or gambling/spending addictions or other self-harming behaviors? If so, please provide information on the support and treatment you have received:

Have you experienced distressing life events (trauma, loss, etc.) that have significantly impacted your functioning and quality of life? If so, please provide information about how you have addressed these issues:

What sparked your interest in this Workshop/Group?

What would you like to accomplish as a result of attending this Workshop / Group?

What previous experience have you had, if any, with group therapy or a support group? Please list approximate dates and the name of the group.

How were they helpful? What difficulties did you have, if any?

What concerns, if any, do you have about participating in a group experience?

How would you respond as a group member if someone in the group dominated the discussion?

How would you respond as a group member if someone never participated in the group discussion?

What else would you like me to know about you?

Thank you for your response thus far! You're almost done! Please read and digitally sign the following to complete your registration.

Coping Agreement and Informed Consent

This is a psycho-educational experience. This means that you will be experiencing interplay between education, and personal processing and growth. This process is presented as a 10 week group. Participation in this experience can result in a number of benefits to you, including improving your relationship with yourself, your interpersonal relationships, and resolution of the specific concerns that led you to seek attendance at a psycho-educational process. During the psycho-educational process, you may also encounter unpleasant feelings or thoughts. You may also make decisions about changes you would like to make in your behaviors and/or relationships. This experience may result in changes that were not originally intended. During the course of this Intensive, Workshop or Weekly Group, I will draw on my professional experience in this area. Attending a psycho-educational process is not a substitute or alternative for individual psychotherapy, or inpatient psychotherapy. If you are in need of names of counselors before, during or after the psycho-educational process, I would be happy to provide you with a list of providers. While this is a psycho-educational experience and not a substitute for therapy, as a licensed clinician, I am still mandated to report serious occurrences such as threat or danger to self, danger to others, or physical, sexual or severe emotional abuse as mandated in accordance with California law. All other information is held in highest confidentiality. I understand and agree that these reportable exceptions are rules set forth to keep children and people safe. I understand that I am agreeing to participate in a psycho-educational experience that carries with it the potential for positive benefits and/or unpleasant feelings. I understand that I may experience both expected and unexpected change. I understand that this is not a substitute or alternative for individual/couples counseling, and that I am free to participate in my own counseling during, or after this experience. I also agree to practice self-care while I participate in this group. If I am feeling overwhelmed, I will slow down, or take a break and step away. I understand that I am free to participate to whatever degree is comfortable for me, and I will not push myself beyond that to meet any perceived expectations of myself or others.

FIRST NAME

LAST NAME

DATE

The Help Her Heal Questionnaire