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15
Questions
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1
Full Name
*
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First Name
Last Name
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2
Phone Number
*
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Please enter a valid phone number.
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3
Email
*
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example@example.com
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4
What is your age?
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5
What is your ethnicity?
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6
Have you been to individual therapy before?
*
This field is required.
YES
NO
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7
Have you worked with PMA Health?
*
This field is required.
YES
NO
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8
Which therapist did you work with?
*
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9
Where did you hear about this group?
*
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10
Have you ever participated in Group Therapy?
*
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YES
NO
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11
Can you briefly describe your experience in Group Therapy?
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12
What do you do hope to gain out of attending this group? What are your goals?
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13
This group will be a commitment, meeting every Thursday from February through May. Is there anything that might get in the way of you attending the group?
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14
Can you commit to attending an in-person group on Thursdays at 6pm from February until May?
*
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YES
NO
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15
What is your marital status?
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16
What is your employment status?
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17
Do you have any special needs, requirements, or accommodations?
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18
Do you consume alcohol?
*
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YES
NO
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19
How often do you consume alcohol?
*
This field is required.
Once a month or less
Once every two weeks or less
Once a week or less
Once every few days
A few times every few days
Onces a day
Multiple times a day
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20
Do you use cannabis?
*
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YES
NO
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21
How often do you use cannabis?
*
This field is required.
Once a month or less
Once every two weeks or less
Once a week or less
Once every few days
A few times every few days
Onces a day
Multiple times a day
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22
Have you used any of the following substances in the past 3 months?
*
This field is required.
Cocaine
MDMA
Heroin or non-prescription opioids
Methamphetamine
Psilocybin (Mushrooms)
LSD
Ketamine
Inhaled Nitrates
GHB
Mescaline
PCP
DMT
Ayahuasca
None of the above
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23
How was it?
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24
Conflict Survey
(scroll down)
*
This field is required.
Never
Rarely
Sometimes
Often
Always
I explore issues with others to find solutions that meet everyone's needs
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
When I find myself in an argument, I usually say very little and try to leave as soon as possible
Row 1, Column 0
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I prefer to compromise when solving problems and just move on
Row 2, Column 0
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Row 2, Column 3
Row 2, Column 4
I am aware when there is conflict with me and another person
Row 3, Column 0
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Row 3, Column 3
Row 3, Column 4
I get into conflict with others over things that do not seem to matter to them
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Row 4, Column 3
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I express anger indirectly, for example, by not speaking to the other person
Row 5, Column 0
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Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
When I am arguing with someone, the argument goes on for a long time
Row 6, Column 0
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Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
I deliberately upset the other person during an argument
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Row 7, Column 3
Row 7, Column 4
I explore issues with others to find solutions that meet everyone's needs
When I find myself in an argument, I usually say very little and try to leave as soon as possible
I prefer to compromise when solving problems and just move on
I am aware when there is conflict with me and another person
I get into conflict with others over things that do not seem to matter to them
I express anger indirectly, for example, by not speaking to the other person
When I am arguing with someone, the argument goes on for a long time
I deliberately upset the other person during an argument
Never
Row 0, Column 0
Rarely
Row 0, Column 1
Sometimes
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Often
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Always
Row 0, Column 4
Never
Row 1, Column 0
Rarely
Row 1, Column 1
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Row 1, Column 2
Often
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Always
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Never
Row 2, Column 0
Rarely
Row 2, Column 1
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Row 2, Column 2
Often
Row 2, Column 3
Always
Row 2, Column 4
Never
Row 3, Column 0
Rarely
Row 3, Column 1
Sometimes
Row 3, Column 2
Often
Row 3, Column 3
Always
Row 3, Column 4
Never
Row 4, Column 0
Rarely
Row 4, Column 1
Sometimes
Row 4, Column 2
Often
Row 4, Column 3
Always
Row 4, Column 4
Never
Row 5, Column 0
Rarely
Row 5, Column 1
Sometimes
Row 5, Column 2
Often
Row 5, Column 3
Always
Row 5, Column 4
Never
Row 6, Column 0
Rarely
Row 6, Column 1
Sometimes
Row 6, Column 2
Often
Row 6, Column 3
Always
Row 6, Column 4
Never
Row 7, Column 0
Rarely
Row 7, Column 1
Sometimes
Row 7, Column 2
Often
Row 7, Column 3
Always
Row 7, Column 4
1
of 8
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25
Bidirectional Communication Survey
*
This field is required.
Never
Rarely
Sometimes
Often
Always
I know when I am having an unpleasant impact on others
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
I am able to identify situations when it would be constructive to provide feedback
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
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I am easily hurt or upset when negative feedback is given to me
Row 2, Column 0
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If someone gives me feedback, I believe it is that person’s problem, not my problem
Row 3, Column 0
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Row 3, Column 3
Row 3, Column 4
When people give me unfavorable feedback, I argue with them
Row 4, Column 0
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Row 4, Column 3
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I do not provide feedback to another person if they are having an unpleasant impact on me
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
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I am told that the feedback I give is excessive and too detailed
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
I know when I am having an unpleasant impact on others
I am able to identify situations when it would be constructive to provide feedback
I am easily hurt or upset when negative feedback is given to me
If someone gives me feedback, I believe it is that person’s problem, not my problem
When people give me unfavorable feedback, I argue with them
I do not provide feedback to another person if they are having an unpleasant impact on me
I am told that the feedback I give is excessive and too detailed
Never
Row 0, Column 0
Rarely
Row 0, Column 1
Sometimes
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Often
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Always
Row 0, Column 4
Never
Row 1, Column 0
Rarely
Row 1, Column 1
Sometimes
Row 1, Column 2
Often
Row 1, Column 3
Always
Row 1, Column 4
Never
Row 2, Column 0
Rarely
Row 2, Column 1
Sometimes
Row 2, Column 2
Often
Row 2, Column 3
Always
Row 2, Column 4
Never
Row 3, Column 0
Rarely
Row 3, Column 1
Sometimes
Row 3, Column 2
Often
Row 3, Column 3
Always
Row 3, Column 4
Never
Row 4, Column 0
Rarely
Row 4, Column 1
Sometimes
Row 4, Column 2
Often
Row 4, Column 3
Always
Row 4, Column 4
Never
Row 5, Column 0
Rarely
Row 5, Column 1
Sometimes
Row 5, Column 2
Often
Row 5, Column 3
Always
Row 5, Column 4
Never
Row 6, Column 0
Rarely
Row 6, Column 1
Sometimes
Row 6, Column 2
Often
Row 6, Column 3
Always
Row 6, Column 4
1
of 7
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26
Disclosure and Interpersonal Closeness Survey
*
This field is required.
Never
Rarely
Sometimes
Often
Always
I am not able to identify when it would benefit me to share my experiences with another person
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
I am aware when it is appropriate to ask people about their experiences
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
I feel the need to keep secrets from people who are close to me
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
I talk about myself and my experiences with other people
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
I do not want to share things about myself with others
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
I ask other people to tell me about their feelings and their experiences
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
I listen to others and offer them support
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
I am not able to identify when it would benefit me to share my experiences with another person
I am aware when it is appropriate to ask people about their experiences
I feel the need to keep secrets from people who are close to me
I talk about myself and my experiences with other people
I do not want to share things about myself with others
I ask other people to tell me about their feelings and their experiences
I listen to others and offer them support
Never
Row 0, Column 0
Rarely
Row 0, Column 1
Sometimes
Row 0, Column 2
Often
Row 0, Column 3
Always
Row 0, Column 4
Never
Row 1, Column 0
Rarely
Row 1, Column 1
Sometimes
Row 1, Column 2
Often
Row 1, Column 3
Always
Row 1, Column 4
Never
Row 2, Column 0
Rarely
Row 2, Column 1
Sometimes
Row 2, Column 2
Often
Row 2, Column 3
Always
Row 2, Column 4
Never
Row 3, Column 0
Rarely
Row 3, Column 1
Sometimes
Row 3, Column 2
Often
Row 3, Column 3
Always
Row 3, Column 4
Never
Row 4, Column 0
Rarely
Row 4, Column 1
Sometimes
Row 4, Column 2
Often
Row 4, Column 3
Always
Row 4, Column 4
Never
Row 5, Column 0
Rarely
Row 5, Column 1
Sometimes
Row 5, Column 2
Often
Row 5, Column 3
Always
Row 5, Column 4
Never
Row 6, Column 0
Rarely
Row 6, Column 1
Sometimes
Row 6, Column 2
Often
Row 6, Column 3
Always
Row 6, Column 4
1
of 7
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27
Emotional Experience Survey
*
This field is required.
Never
Rarely
Sometimes
Often
Always
I am aware of my feelings and emotional experiences as they are happening
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
I express my emotions in an overly intense manner
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
I express my emotions at appropriate times and places
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
I intentionally hide my feelings
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
I try not to feel certain emotions
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
I am able to put a name to what I am feeling
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
I clearly communicate my emotions to people so that they know exactly how I feel
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
I am aware of my feelings and emotional experiences as they are happening
I express my emotions in an overly intense manner
I express my emotions at appropriate times and places
I intentionally hide my feelings
I try not to feel certain emotions
I am able to put a name to what I am feeling
I clearly communicate my emotions to people so that they know exactly how I feel
Never
Row 0, Column 0
Rarely
Row 0, Column 1
Sometimes
Row 0, Column 2
Often
Row 0, Column 3
Always
Row 0, Column 4
Never
Row 1, Column 0
Rarely
Row 1, Column 1
Sometimes
Row 1, Column 2
Often
Row 1, Column 3
Always
Row 1, Column 4
Never
Row 2, Column 0
Rarely
Row 2, Column 1
Sometimes
Row 2, Column 2
Often
Row 2, Column 3
Always
Row 2, Column 4
Never
Row 3, Column 0
Rarely
Row 3, Column 1
Sometimes
Row 3, Column 2
Often
Row 3, Column 3
Always
Row 3, Column 4
Never
Row 4, Column 0
Rarely
Row 4, Column 1
Sometimes
Row 4, Column 2
Often
Row 4, Column 3
Always
Row 4, Column 4
Never
Row 5, Column 0
Rarely
Row 5, Column 1
Sometimes
Row 5, Column 2
Often
Row 5, Column 3
Always
Row 5, Column 4
Never
Row 6, Column 0
Rarely
Row 6, Column 1
Sometimes
Row 6, Column 2
Often
Row 6, Column 3
Always
Row 6, Column 4
1
of 7
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28
Is there anything else you would like us to know? Do you have any questions?
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