ABCs of Healing Registration

Admit. Believe. Commit. A Gospel-Centered Journey of Prayer and Restoration

This form helps us ensure ABCs of Healing is a good fit for you at this time. There are no wrong answers. Your responses are confidential and will be reviewed only by Pastor Alex to discern how we might best help support you in your journey..

YOUR INFORMATION

Name

This address will receive a confirmation email

Phone

Address

ABOUT YOU

These questions help us understand where you're at right now. Answer as honestly as feels comfortable — you can always share more in a follow-up conversation.

1. What's drawing you to this group at this time? (No need to share everything — just what feels relevant.)

2. How would you describe your current day-to-day functioning?

Generally managing well, though carrying something difficult Some days are hard — my functioning is affected in limited ways I'm struggling significantly — daily life feels hard to sustain I'm in a place of crisis or acute distress right now

3. Are you currently able to care for your basic needs — sleep, eating, personal hygiene, leaving the house?

Yes, consistently Yes, but with difficulty Inconsistently No, this is a struggle right now

4. In the past month, have you experienced any thoughts of harming yourself or ending your life?

No I've had passing thoughts but no intention or plan Yes — this is something I'm actively dealing with

If you checked the third option, we'd like to connect with you personally before the group begins. You are still welcome. We just want to make sure you have the right supports in place.

5. Are you currently connected with any of the following? (Check all that apply)

A therapist or counsellor A psychiatrist or physician for mental health support A support group None of the above

If you're not currently connected with professional care, that's okay. We can help you explore options as part of this process.

6. Has anything significant happened recently that feels destabilizing — a loss, trauma, major life change, or crisis?

No Yes — things feel somewhat unsettled Yes — I'm in the middle of something acute right now

If yes, briefly describe if you're comfortable doing so:

7. Group settings can sometimes bring up unexpected emotions or memories. How do you tend to respond when difficult feelings surface?

I can usually stay present and grounded I sometimes feel overwhelmed but can recover I tend to shut down or dissociate I'm not sure — I haven't been in a setting like this before

8. Is there anything about your current situation that you think Pastor Alex should know before the group begins?

A NOTE BEFORE YOU SUBMIT

ABCs of Healing is a pastoral, prayer-centered group. It is not therapy or clinical treatment. It is designed to run alongside professional care, not instead of it. Participants experiencing acute crisis, active suicidal ideation, or significant instability will be lovingly encouraged to access professional support before or alongside joining the group. This is not a barrier; it is a safeguard, because we want this to be genuinely helpful.

If you have questions about whether this group is right for you right now, please reach out to Pastor Alex directly. No question is too small.

CONSENT

I understand that ABCs of Healing is a spiritual support group, not a clinical service I understand that my responses will be held in confidence by Pastor Alex give permission for Pastor Alex to follow up with me before the group begins if needed I understand that if my needs exceed the scope of the group, I will be supported in accessing appropriate care

Type your name as a signature

Questions? Contact Pastor Alex at alex@courtenaybaptist.com or 250-334-3432

ABCs of Healing Registration

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