Support Group Intake Form | Center for Hope WNY

Fields marked with an * are required

Financial assistance is available!

Are you seeking financial assistance? *

Yes

First Name *

Last Name

Email *

Phone *

May we contact you at the information above? *

Yes

Are you currently involved with your partner? Please (briefly) explain your current living situation: *

Is there currently or has there even been Orders of Protection in your relationship? Are you currently in court for any reason? *

What are you hoping to derive from attending this support group? What are your goals? *

Is there any other information that you would like to share with our mental health counselors that may be relevant to your personal situation or your involvement in this group? *

When would you prefer to participate?

Fall

Winter

Spring

Summer

Please indicate how you wish to participate in this group: *

In person (Buffalo)

In person (East Aurora)

Virtual

No preference

Please indicate your preference for group:

Single gender

Mixed gender

No preference

Demographic Information Needed for Grants

This section is completly optional: The following information is demographic information we need to collect as a non-profit for grant purposes. No personal information will be given out attached to your name or any private information. All of our client information is strictly confidential.

Age

Gender

Ethnicity

# Children

Education

Employment

Personal Income

Household Income

Please check off the following statements to indicate your understanding and consent: *

This support group runs for 6 consecutive weeks. Support group dynamics are such that regular attendance is essential for all members to derive the most benefit. I am prepared (absent unanticipated emergency) to commit to attending all 6 sessions. I understand that if I fail to attend that payment is non-refundable.

Center for Hope WNY does not make any guarantees that services will have benefits. This group is psycho-educational and each person who attends may experience different results.

I understand that the identity of any person attending this group, the location of the group and the content of anything discussed in group is confidential and may not be disclosed or shared with anyone outside of the group.

I understand and agree that all materials shared in group are the property of Center for Hope WNY and may not be duplicated or shared without consent.

I consent to allow the support group facilitator to disclose information regarding my participation in the Narcissistic Abuse recovery support group to any other Center for Hope, WNY provider that I am currently working with as it relates to my participation in the support group.

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