UnHooked! Coaching Support Group Intake Form

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I am very excited to have you join in the upcoming UnHooked! 7 Steps To Emotional Freedom coaching support group!  I would ask you to fill out the following  questions in order for me to get a better picture of who you are and your interest and expectations of the group. 

Once I receive your information I will recontact you with all the details for registration

Please fill out this form and send it back to me as soon as possible. THANKS

*Your Name:

*Your Email address:

*Phone # :

Skype Name :

*Your Time Zone:

*Your Mailing Address (to send certificate)

*Have you completed the UnHooked! book?

If not completed, what Step did you complete?

*Have you been in an online coaching group before?

*Why have you decided to participate in this group?

*What goal(s) are you wanting to reach in this group?

*What trauma are you working towards healing from in this group?


The following questions will help me to know if there are any specific areas of need you are dealing with:

*Are you suicidal at this time?

*Have you ever attempted suicide in the past?

If yes, when and how did you attempt?

*Are you self harming at this time? If yes, how?

*Have you self harmed in the past?

*Are you taking any prescription medications at this time?

If yes, what kind are they? How long have you been taking them?

*Do you use alcohol or drugs?

If yes, what kind and how much do you use?

If yes, are you concerned about your use?

Do you have any unanswered questions about the upcoming group?

Is there anything else you think I should know about in order to help me better support your needs during this group time?

All information on this intake is confidential and is only for the use of Karis Counselling Services (KCS). Yet, there are circumstances in which KCS would be compelled to break confidentiality; if we believe you are at risk for suicide, if we believe you intend to harm another person, or if we are required by the law to do so. Also, information on this intake form may be used for data resource gathering without any identifying information being disclosed.

I understand and agree that all the information provided to Karis Counselling Services is accurate.

*Signed:



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