Thank you for registering for (re) define Courage.

We are excited that you are joining us! If you have any questions, please email Rebecca.

Now that you’re on board, please take a few minutes to fill out our (re) define Courage client questionnaire, below. This will help us get to know you and serve you better. NOTE:  Your payment holds your space in a workshop cohort but your spot will not be confirmed until you complete this form.

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(re) define Courage Client Questionnaire

Your Name (required)

Your Email (required)

Date

Which Workshop series or Intensive do you want to attend? Note: If there is more than one option, please indicate your order of preference.
Weekend Intensive 1) 2) 3) (please fill in weekend preferences ranked in order)
Weekly Workshop (please fill in Cohort preference)

Age

Date of Birth

Occupation

Employer/School

Marital Status
SingleMarriedDivorcedWidow(er)SeparatedPartneredRemarried

Do you have children?
YesNo

If yes, names and ages:

Who lives in your home?

Home address

Primary phone

Ok to leave messages?
YesNo

Secondary phone

Ok to leave messages?
YesNo

Would you like to be included on the Potentia email list?
YesNo

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

If yes, when? Please briefly list the reasons.

Do you have a therapist you could work with if something came up in the group requiring individual attention?

If not, would you like referrals to therapists?
YesNo

Are you currently taking any medication for mental health issues?
YesNo

Any other medications? If yes, 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 or disordered eating? If so, please provide information on the support and treatment you 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 the (re) define Courage Workshop and/or Intensive?

What would you like to accomplish as a result of attending the group?

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

What worked well for you?

What difficulties did you have, if any?

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

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 us to know about you?

What is the best way to follow up with you?

Thank you so much for providing this information! Please click the button below to send this form to Rebecca Bass-Ching, LMFT, MFC #44584, who will follow up with you to discuss workshop placement and, if you have not previously worked with Molly or Rebecca, schedule a pre-group session.

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If you haven’t yet, click here to be notified when additional workshop details are available. You can also go here to sign up for more news from Potentia.

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