Intake Form

Date(Required)

Interviewer's Name:(Required)

First Last

Intaker's Email:(Required)

Particpant's Name:(Required)

First Last

Participant's Status: (check all that apply)(Required)

Person with Cancer

Person that had Cancer

Caregiver

Type of Cancer:(Required)

If caregiver, name of person with cancer:

Relationship:

Support Group Name & Number:

Support Group Facilitator:

Present Life Situation (describe support network, work & extracurricular activities, how Participant is dealing with the illness):

Significant Stressors in the last few years:

Reason for joining a Support Group (Expectations, questions, concerns):

Experience in Support Group:

Currently in psychotherapy?:

Previous Hospitalization for Mental Condition? (If yes, describe)

Interviewer’s comments (describe appearance, general attitude, willingness to disclose information, anything facilitator should know):