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Application for Grace Groups

Orientation Sunday, January 31 at 6pm

Group begins February 19, 2010

There is a $25 Registration Fee
* Last Name
* First Name
* Sex
* Age
* Email
* Address
* City
* State
* Zipcode
* Phone - Home
* Phone (other/emergency)
* Church Affiliation
* Occupation
* Marital Status
* Children
How Many Children?
How did you hear of this Ministry?
* Have you ever been a part of a small group ministry to survivors of abuse.
If yes, were you a
How would you evaluate its effectiveness?
* Other Small Group Experience?
  Were you abused in any of the following ways:
Before proceeding with this question, please read the definitions of abuse.
  If your answer is NO to the next questions, Please complete the following two fields with a NO answer
* Domestic/Spousal?
* Age
* Relationship of abuser to you
* Emotional?
* Age
* Relationship of abuser to you
* Physical?
* Age
* Relationship of abuser to you
* Satanic Ritual Abuse?
* Age
* Relationship of abuser to you
* Sexual?
* Age
* Relationship of abuser to you
* Spiritual?
* Age
* Relationship of abuser to you
* Verbal?
* Age
* Relationship of abuser to you
* What were the events surrounding the wound, abuse, or disappointment?
* How long did it go on?
* How did you deal with it?
* Was there anyone who could have protected you?
* Did they help you? If not, how did you feel toward them?
* At what age did you first talk about your abuse?
* Who did you talk to and what was their response?
* Have you received any lay or professional counseling?
* If "yes" for what issues
* How long have you been, or were you, in couseling?
* Have you discussed your intention to attend this group with your counselor?
* If "yes", what is his/her opinion?
* What other help have you pursued in your healing, if any?
* Are you aware of being, or have you been diagnosed as being dissociative?
* Explain, if necessary
* What are your personal expectations for this ministry?
* If you are a returnee of a group using this material, please include the names of your former leaders
* Have you read the booklet, "When Trust is Lost"?
* Have you read the book, "Wounded Heart"?
* Additional Comments you want to share
 


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