Intelligent Relationships

Private and Confidential

Name: *

Preferred gender pronouns: *

Date of birth *

Address

Street Address *

Email address: *

Contact telephone number: *

Nationality: *

Occupation: *

Any post-school educational qualifications: *

Religion: *

Please say something about your living situation – for example, do you live alone, or in a flatshare/houseshare, or with your parents/other relatives, or with a partner, and with or without children, or with your child/children but not with a partner, etc: *

What previous experience do you have of being in a group, if any? What kind of group/groups? *

What do you most hope for out of joining this group? *

If you were to have any concerns about joining this group, what would you be concerned about? *

Are you currently in a relationship? *

How is your physical health in general? *

How is your mental health in general? *

Are you currently living with any medical/psychological diagnosis? *

Are you on any medication? *

What is your average weekly level of alcohol consumption, if any? *

What is your average weekly level of recreational drugs consumption, and of which kind, if any? *

Have you ever had a criminal conviction? *

Have you had any experience of being in therapy? (e.g. personal therapy, couples therapy, group therapy) If so, is it past or currently ongoing, and what kind of therapy? *

Is there anything else you’d like us to know about you, e.g. with regard to sexuality, ethnicity, or anything else? *