Joy Comes in the Mourning Intake Form
Joy Comes in the Mourning Intake Form
Date
Date
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Name
Name
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First
Last
Confirm name, DOB, and methods of contact given on screening.
Indicate any changes below:
Maritial Status:
Maritial Status:
Married
Single
Engaged
Divorced
Widowed
Other
Other
Occupation/School
Pregnancy Related
How many pregnancies have you had and what were their outcomes?
Abortion History
What is your reason for seeking Post Abortion Recovery?
How many abortions experiences have you had? Can you tell me about each?
(age, relationship, how many weeks, what impacted these decisions)
Additional space for comment:
(physical complications, impact, etc)
Have you ever share your abortion experiences with anyone? if so, who?
What impact has your abortion(s) had on you? (Review PAS symptoms, substance & drug abuse, etc)
Spiritual Intake:
What are your spiritual beliefs?
What were your beliefs at the time of your abortion experience(s)?
Some of the materials used in our recovery courses are biblically based. Are you comfortable with that?
Some of the materials used in our recovery courses are biblically based. Are you comfortable with that?
Yes
No
Other
Other
What is your understanding of forgiveness? Do you feel forgiven?
Do you have a class preference?
Do you have a class preference?
Individual coaching
Joy comes in the Mourning Group
Do you have a history of mental health issues, substance or drug abuse or addiction?
If so, have you received treatment?
I understand this is a legal representation of my signature. I give permission for Soundview's Director of Client Services & Post-abortive Group Volunteers to review & retain information shared above in confidentially.
Draw your signature into the box below.
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Full Name