Name *

First Name

Last Name

Phone *

(###)

###

####

Where are you currently in your faith journey? *

Actively leaving LDS

No longer affiliated

Processing past experiences

Other

Are you currently part of any religious or spiritual community?

Yes

No

Are you currently in individual therapy? *

Yes

No

Have you experienced spiritual abuse or trauma in the LDS Church or elsewhere? *

Yes

No

Do you have a history of suicidal ideation or self-harm? *

Yes

No

If yes, are you currently experiencing those thoughts?

Yes

No

Occasionally

Have you ever participated in group therapy before? *

Yes

No

Do you feel emotionally ready to listen to and support others, even when experiences may differ from yours? *

Yes

No

Unsure

Do you identify with any of the following? (optional, check all that apply)

BIPOC

LGBTQIA+

Neurodivergent

Diabled

Survivor of abuse

Single parent

Other: