Adult OCD Treatment Group Intake Form

Light On Anxiety OCD Treatment Group Intake

Helpful Tip Before You Start
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Attendance Commitment*
To join the Light On Anxiety Adult OCD Treatment Group, you must first conduct an individual treatment planning session. (Note: This may not be required if you are a current Light On Anxiety client.) If it is determined you will benefit from participating in the ERP for OCD treatment group, you must be able to commit to attending at least 8 out of 10 sessions in the first 10 weeks of your participation. To schedule an individual treatment planning session, please contact us at [email protected] or (312) 508-3645.
- I acknowledge that I understand the attendance commitment policy.
Patient Legal Name*
First Last
Patient Date of Birth*
Month
Day
Year
Patient Email*
Group Therapy Informed Consent
What can I expect from the Adult OCD Treatment Group?

The Adult OCD Treatment Group at Light On Anxiety will provide you with an opportunity to connect with others and participate in action-oriented, hands-on exposures to help you move through and past your OCD symptoms. We strive to maintain an environment where each group participant will feel respected and valued while working towards their individual goals.

Confidentiality

You have the expectation of privacy in group sessions. The information you share is confidential and will not be disclosed by the Light On Anxiety therapist without your written permission unless required under Illinois and Federal law. Disclosure is required by law if you may pose a danger to yourself or others.

All members of the group are expected to maintain a high level of confidentiality in group sessions. This means each participant agrees not to share any other group member's identifying and personal information with others. Conversations and stories shared within the group are not to be discussed with anyone outside of the group.
Consent to Treatment*
I consent to treatment. I acknowledge receipt and understanding of Light On Anxiety's Group Therapy Informed Consent, and agree to all its terms and conditions. I acknowledge and agree that this additional Informed Consent does not negate or replace any conditions of Light On Anxiety's general Informed Consent, which remains in full force and effect.
Date*
MM slash DD slash YYYY
Print Name of Signee*
Signature - Consent to Treatment*
Clinical Information
What is your treatment goal for this group?*
What are the top three mental health problems you are experiencing?*

On a scale of 0-10, how much distress do these problems cause for you?*

Challenge 1	Challenge 2	Challenge 3

On a scale of 0-10, how motivated are you to move past each of these problems?*

Challenge 1	Challenge 2	Challenge 3

What strategies / treatments have you tried to address these challenges in the past?*
What previously interfered with you moving past these challenges?*
How have you been coping with this problem until now?*

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Light On Anxiety OCD Treatment Group Intake

Helpful Tip Before You Start

Group Therapy Informed Consent

Clinical Information