Healing From Depression and Anxiety Support Application Form Support Group ApplicationName* First Last Date of Birth* Today's Date Address Street Address City State / Province / Region ZIP / Postal Code Home Phone*Work PhoneEmail* Cell PhoneGenderMaleFemaleTransgenderMarital StatusSingleMarriedDivorcedSeparatedWidowedCurrent OccupationEmergency Contact Person First Last Emergency PhoneWhat would you like to accomplish through this class?Please check any of the following that concern you: Nervousness Fears Anxiety Job Issues Nightmares Concentration Loneliness Low Energy Bowel Problems Parenting Issues Legal Issues Depression Hopelessness Anger Divorce / Separation Insomnia Shyness Eating Disorders Headaches Sexual Abuse Career Choices Obsessive Thoughts Suicidal Thoughts Finances Grief Making Decisions Isolation Health Problems Stomach Problems Memory Problems Sexual Problems Inferiority Problems Other Have you ever received (or are you now receiving) counseling or psychiatric treatment?YesNoIf yes, please explain.Have you received a mental health diagnosis (e.g., depression, anxiety, bipolar disorder, etc.)?YesNoIf yes, what is it?Name of current counselorCurrent counselor phoneName of current prescriberCurrent prescriber phoneList any medications or supplements you are currently taking.Have you ever had to struggle with an addiction to alcohol, drugs, and eating disorder, etc.?YesNoIf yes, please explain.List any recent or current health problems.On a scale of -5 to +5, where -5 is severely depressed, 0 is neutral, and +5 is extemely happy, what number would you rate your mood on a typical day?-5 severely depressed-4-3-2-10 neutral12345 extremely happyCheck the evenings of the week that are best for you. Monday Tuesday Wednesday Thursday Friday What are your current goals in life? Do you have a vision or creative project that you are working towards?What type of support do you think you need to make your goals a reality?What obstacles might be getting in your way?Other comments or relevant information.How did you learn about the group?CommentsThis field is for validation purposes and should be left unchanged.