Upcoming Groups

 

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Group Application

This is a screener whose purpose is to help select those most likely to benefit from this counseling group. Please answer honestly.

All information submitted in this application is encrypted and transmitted securely.


Are you currently experiencing any thoughts or harming yourself or others?


If you are in crisis and considering hurting yourself or someone else, please contact your local crisis line. The Multnomah County Mental Health Crisis Line is 503-988-4888. Clackamas County: 503-655-8585. Washington County: 503-291-9111. Clark County: 360-696-9560.


Date you gave birth:


Is this your first child?


Are you currently breastfeeding?



How did you find out you have low milk supply?



Do you know the suspected reason for your low supply?



Who is in your support network?




If you have a support network, how would you describe the quality of the support?





When I feel like I'm struggling:




I feel sad and hopeless:




I look forward to things:




I have been crying:




Does it bother you when someone else receives more attention than you?


Does it often seem like people may be trying to cheat or take advantage of you?


Do people often say that you don't have much empathy for their problems?


Please indicate whether you experienced any of the following as a child or adolescent:

Yes  

No
Did you feel alone or that you had to fend for yourself because you had no one to protect or take care of you?
Did you lose a parent through abandonment, death, or incarceration?
Was anyone in your household mentally ill, or did anyone in your home attempt suicide?
Did a parent or adult in your home have a substance abuse problem?
Did you live with anyone who was incarcerated?
Did a parent or adult in your home ever tell you you're worthless, or put you down in other ways?
Did a parent or adult in your home ever physically hurt you?
Did you feel unloved?
Did you experience other people in your life crossing your boundaries?
Would you like to provide more information?

Some people sometimes feel as if they are watching themselves do something. Does this ever happen to you?




Do you ever experience a feeling that your body does not seem to belong to you?




Do you ever remember a past event so vividly that it feels as if you are re-experiencing the event?




Do you ever find yourself in a place but don’t know how you got there or why you’re there?




Have you ever attended group or individual counseling?

Approximate Dates:


Approximate Dates:



Are you currently receiving counseling?

Where:


Where:


Are you comfortable with extensive self-disclosure in a small group setting?




In a small group setting, would you be able to engage in non-judgemental acceptance of others?


How did you hear about this group?




What are your hopes for this group?


Can you commit to attending group for 8 weeks (with exceptions in the event of emergency, illness or holidays)?

This is an 8-week group, and attendance is vital.






Some questions are based on items from the Edinburgh Postnatal Depression Scale, Patient Health Questionnaire-9, Adverse Childhood Experience Questionnaire for Adults and the Iowa Personality Inventory.