Group Application Form

A warm welcome to you! Please complete the following application to the best of your ability. Whilst some questions might feel a little personal, our goal is to keep the online space safe, so that we can build a solid, stable environment for everyone. Your answers are confidential. Please answer to the best of your ability, but don’t worry if any parts are difficult to answer, as we can discuss this in your individual assessment. Many thanks.

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Name

Phone

Address 1

Address 2

Town/City

Country

Post Code/Zip Code

Have you had therapy before?

Please can you tell us a little about why you are seeking therapy/group therapy at this time?

Have you had a formal Mental Health Assessment?

Do you have a Psychiatrist/Mental Health Nurse?

Do you have any formal mental health diagnosis? (e.g., PTSD/CPTSD or Depression, Bi-Polar…)

If Yes, can you please record it here? (Note, any diagnosis will not affect your right to access the group. We are asking because it will help to know where you might be with regards to formal treatments).

Are you on any prescribed medication or are you dependent on any substances?

If yes, please give details.

Please share any other information that you feel is relevant to your application. To best meet your needs, please include anything that you feel would be helpful for us to know. (For example, is there anything you might need to tell us about things that might trigger you? Is there an underlying health condition, neurodivergence or phobias that might need to be supported in a particular way? Do we need to be aware of any specific history that might make it difficult to feel safe in a group? We hold this information that you provide in a non-judgemental frame and the questions are here to support best practice).

The groups will be held online. In an ideal situation, you will be in a safe and private environment, and we would like to be able to see at least your head and shoulders. Because we work with the body and look at somatisation, we may do certain exercises together (e.g. breathing, stretches, visualisations etc). This might require some freedom of movement. If possible, therefore, we would ask that your computer/phone or tablet is in a fixed position, (not held in the hand or on your lap), and that you have some usable space around you.

It is important for the safety of all group clients that no-one outside the group can overhear or join in with the group, especially given the potential histories of yourself and other clients. We do accept that working online brings with it some risks around boundaries, as we cannot always control our environments – so don’t worry if the setting is complicated! However, we would ask that you sign below to show that you have read this so that we are comfortable that all group members will do their best to maintain a good space and safety for the work.

Please sign to confirm you have read the above.