Thank you for your interest in joining our Relationship Recovery Process group!

March 4th, 2025-September 2025

This is a 6 month long therapy group intended for those that are committed to deeper growth and healing around childhood trauma and improving their current relationships. Working together with a therapist in a group setting can provide a unique form of healing within community. Filling out this form will give us a better understanding of whether this group is right for you! All participants will have a follow up free consultation call with our therapist Ari, and you will be able to explore how the group could support your goals.

USE THIS FORM TO REGISTER FOR OUR RRP Group

Group: RRP Group

When: Tuesdays 5:15-6:30pm (75 minutes) , Skipping major holidays

Where: Remote/ Online

Participants: Limited to 8 participants

Facilitator

Ari Rogers Registered Associate Marriage Family Therapist # 136411 supervised by Julia Cushing LCSW #108448.

Cost: $1080 per group - paid in two installments.

-$540 non refundable deposit due before Tuesday 2/25/25

-$540 at the midpoint due before 6/4/2025

Your Full Name

Your Preferred Name (if different)

Your Current Address *

Your date of birth (DOB) - XX/XX/XXXX format *

XX/XX/XXXX

Your Gender *

Female
Male
Non-binary / gender non conforming
Two Spirit
Other
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Your Phone # *

Please use format above

I consent to receiving text messages from Rose Wellness at this phone # regarding my inquiry and availability. *

Yes

You can text STOP to unsubscribe at anytime

Your Email *

Or primary contact email if filling out for a minor

Your Age *

____ Years old

Do you identify as transgender?

Yes
No
Unsure
Prefer not to say
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Your pronouns *

Ex: She/Her

How did you hear about us? *

A friend
A current client
Psychology Today
Google Search
Another Professional
Instagram
UCSB/ CAPS
Flyer
School
Other
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These are some questions that will help us get to know you better, and help determine whether or not this group would be right for you!

Are you experiencing any stressors in the last 6 months, that create instability in your life? *

Divorce

Homelessness

Domestic Violence

Mental Health Hospitalizations

Addiction

Legal involvement

None

Are you currently residing with your family of origin? (i.e. siblings, parents, guardians..etc) *

Yes
No
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How much distress do your current relationships (work, intimate, familial ) cause in your life currently? *

None at all
Mild distress
Moderate distress
Severe distress
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Have you sought out any information/ resources on childhood trauma on your own? (books, podcasts..etc)

Are you currently seeing a therapist/counselor? *

Yes
No
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How much experience with therapy do you have with a mental health professional? *

0-1 years of psychotherapy
1-3 years of psychotherapy
3-5 years of psychotherapy
5 + years of psychotherapy
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Have you discussed/ Processed childhood trauma with a mental health professional before this? *

No, I have not
A little bit
A fair amount
At length/ A lot
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How often did you feel safe in your home growing up (emotionally and/or physically)? *

Never
Rarely
Sometimes
Often
All the time
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Growing up, did you feel like you were treated or expected to be an adult or take care of the adults in the home? *

Yes, all of the time
A lot of the time
Sometimes
Rarely
Never
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Would you say your emotional and developmental needs were seen and met as a child/adolescent? *

(If you feel comfortable sharing) How would you describe your childhood trauma?

Suicidal Ideation -Have you thought about killing yourself either currently or in the past? *

Never

Sometimes

I have but it's been a while

I think about it, but I don't want to act on it

I think about it and I'm afraid I might act on it

Please check all that apply.

Self Harm- Have you intentionally hurt or caused your own body harm either currently or in the past? *

I used to intentionally harm myself

I currently intentionally harm myself

I've never intentionally inflicted harm on my own body

Please check all that apply

Alcohol - How often do you drink alcohol? *

None, I don't drink alcohol

1-3 drinks per week

4-10 drinks per week

10+ drinks per week

Drug Use - Do you use any other drugs or substances that alter your state of conciousness and may impact your ability to participate in the group? *

Yes

Maybe

What are you hoping to accomplish or gain from being in RRP Group? *

Participation is what makes a group most successful! Are you able to participate in the group without missing 3 or more meetings? *

Yes, I can commit to missing 3 or less
Not at this time, but I'd like to join for next cycle!
I'm not sure
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