Assessment for Small Group Participation
  1. The Emotional Health ministry is designed to promote a spiritual and emotional healthy environment. We currently offer a variety of support groups that deal with various emotional and spiritual health issues. Please give your honest opinion to the following questions. Your answers to this assessment will be kept confidential and will help in finding the ideal fit for you in a support group. If you know the specific group you want to attend, please list the name of that group under "what type of support group are you interested in." The assessment works best on a desktop computer - you may have problems completing form on a cellphone or tablet. Also on the assessment, if you don't have any children, please put one child (form will not accept 0 children).
  2. First Name(*)
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  3. Last Name(*)
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  4. Age(*)
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  5. Email Address(*)
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  6. Mailing Address(*)
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  7. Phone #(*)
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  8. Emergency Contact Name(*)
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  9. Emergency Contact Number(*)
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  10. Marital Status(*)
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  11. Number of Children(*)





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  12. Are you a member of the POA(*)
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  13. If "YES", how long?
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  14. What ministry areas are you involved in, and for how long have you been involved?
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  15.  
  1. What type of support group are you interested in?
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  2. What do you expect this group to provide?
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  3. How would you like to be different at the end of this group?
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  4. Have you ever participated in a support group? If so what type?
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  5. Are you willing to commit to being in all group sessions and on time?
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  6. If you know, please tell us what group you are interested in?
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  7.  
  1. Answer the items below by clicking in the appropriate box.
  2. 1. I am willing to participate in a group with people who may have different ways of dealing with issues similar to my own?





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  3. 2. I enjoy being part of a group.





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  4. 3. I am willing to listen to other people's difficulties.





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  5. 4. I could benefit from the experience of others facing similar situations.





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  6. 5. I am comfortable when talking about my feelings.





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  7. 6. Is it necessary to provide a safe, secure, and welcoming environment in groups?





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  8. 7. Are you willing to respect the confidentiality of members' discussions?





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  9. 8. I do not agree with the perception of joining a group as a "sign of weakness."





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  10. 9. I am willing to try new behaviors.





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  11. 10. What would you consider barriers in a support group? Please explain.
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  12. Please enter the characters you see.(*)
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