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 9
Contact Information: Please include full name, phone number and email address.
Question 2 of 9
What brings you to a Change Group? What are you wanting to work on? (May select multiple Choices).
Addiction(s): Food, sex, pornography, alcohol, drugs, gambling etc.
Anger/ Irritability
Anxiety/ Fear
Blaming
Black & White/ All or Nothing Thinking
Control/ Insecurity
Criticism/ Gossip/ Judgements
Depression/ Hopelessness/ Despair / Feeling Lost or Without Direction
Obsession with Body Appearance
Obsession with Relationships
Overwork/ Busyness
Procrastination / Confusion / Denial
Religiosity / a Pharasaical Spirit
Self- Pity
Question 3 of 9
Length of sobriety?
3-6 months
6-9 months
12+ months
Question 4 of 9
How do you think Change Group will help you?
Question 5 of 9
On a scale of 1-5 how willing are you to change? Not willing = 1, Very Willing = 5.
1
2
3
4
5
Question 6 of 9
On a scale of 1-5: Are you willing and able to give and receive support from others?
Strongly Disagree
Disagree
Unsure
Agree
Strongly Agree
Question 7 of 9
Are you currently involved in any legal matters (pending court dates, out standing warrants, investigations etc). If yes, please explain.
Question 8 of 9
Would you like to chat with a coach before completing registration?
Yes
No
Question 9 of 9
How did you hear about Genesis Process?