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Kelly's Change Group Assessment

This screening is designed to help determine if a participant is ready for a Genesis Change Groups experience. Genesis Change Groups focus on healing underlying wounds, building safe relationships, identifying relapse patterns, and developing long-term recovery and life-change tools.  


 

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Question 1 of 5

Contact Information: Please include full name, phone number and email address. 

Question 2 of 5

Select the main problem you'd like to change or work on in our group. 

A

Addiction(s): Drugs, alcohol, pornography, gambling.

B

Anger

C

Anxiety

D

Depression

E

Fears

Question 3 of 5

 

Motivation for Change: I am willing to look honestly at unhealthy patterns and behaviors.

 
A

Strongly disagree

B

Disagree

C

Unsure

D

Agree

E

Strongly Agree

Question 4 of 5

On a scale of 1-5: How willing are you to give and receive support from others?

A

Strongly Disagree

B

Disagree

C

Unsure

D

Agree

E

Strongly Agree

Question 5 of 5

How do you think Change Group will help you?

Confirm and Submit