Please be advised that this group is not for those who are having suicidal ideation. If you are suicidal, call 9-1-1 immediately. ANXIETY AND DEPRESSION GROUP INTAKE Your Name* First Last Age* Telephone Number* Email* Current living situation* Campus or Church attending* Victory Norcross Victory Hamilton Mill Victory Midtown Victory Online Name of emergency contact* First Last Telephone number of emergency contact* Emergency contact relationship to you* Do you currently have thoughts of suicide?* Yes, I have thoughts of suicide Yes, and I have a plan No, I do not have thoughts or a plan of suicide Please call 9-1-1 immediately.Emotional Status* Select All Anger Anxiety / panic attacks Suicide Depression Mood Swings Confusion Fear Breakdowns Addictions Other If "other", please explain.*Select items that identify areas of concern for you.* Select All Addictions (alcohol, drugs, food, gambling, sex, etc.) Education / learning difficulty Eating difficulty Marital problems Physical health problems Problems with social relationships Financial problems Mental health problems Problems with children Problems with parents Religious / spiritual concerns Sexual concerns Thoughts of suicide Decision making difficulty / confusion Unhappy most of the time Addiction of a family member Work / job related Worry Current trauma Past trauma Loneliness Feeling abandoned Other If "other", please explain.*Describe the problem which prompted you to reach out at this time.*Are you currently in a doctor's care for any physical, mental, or emotional issues?* Yes No With whom and for what?Have you been prescribed medication?* Yes No Are you taking the prescribed medication? (select N/A if not applicable)* Yes No N/A Have you ever been in a mental or psychiatric facility?* Yes No For what reasonHave you ever been arrested, charged, or convicted for any criminal offense?* Yes No Have you ever been refused entrance into a group or organization?* Yes No Have you ever (or currently) used illegal drugs/substances?* Yes No What drug(s) and how often?Have you ever (or currently) used alcohol to cope?* Yes No How often?What is your purpose for joining this class / group?*NotesWhat do you hope to gain from the group?*Have you experienced ‘church hurt’ from a church or spiritual leader?* Yes No If yes, please explain*How do you cope with offense?*What is your relationship with God?* I am not a believer but I want to be I make it a priority to spend time with God I am a believer but angry or disappointed with God I have no interest in a relationship with God Required DocumentationPlease read and review the ReNew Code of Conduct. Click here to review. Please read and review the Renew Care Group Waiver and Life Plan. Click here to review. Please read and review the Life Covenant. Click here to review.I have read, understand and agree to the Renew Code of Conduct, Renew Care Group Waiver and the Life Covenant.* Yes No I understand that this is not a therapy group and I release Victory Church of any liability. Click here to review the Statement of Faith.Digital Signature Box* Today's Date* MM slash DD slash YYYY
