“Healing From Depression and Anxiety” Class Application Form
Name
Date of Birth Today's Date
Street Address
City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist. of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code
Home Phone Work Phone
Cell Phone Email Address
Sex: Male Female Marital Status: Single Married Divorced Separated Widowed
Present Occupation
Emergency contact person Emergency Phone
What would you like to accomplish through this class? Please check any of the following that concern you:
Have you ever received (or are you now receiving) counseling or psychiatric treatment? Yes No If yes, please explain. Name of current counselor Phone Name of current prescriber Phone
List any medications or supplements you are currently taking.
Have you ever had to struggle with an addiction to alcohol, drugs, and eating disorder, etc.? Yes No If yes, please explain
List any recent or current health problems
On a scale of -5 to +5, where -5 is severely depressed, 0 is neutral, and +5 is extemely happy, what number would you rate your mood on a typical day?
Check the evenings of the week that are best for you Mon Tues Weds Thurs Sat
What are your current goals in life? Do you have a vision or creative project that you are working towards?
What type of support do you think you need to make your goals a reality?
What obstacles might be getting in your way?
Other comments or relevant information
How did you learn about the group?
