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Birthparent Services

Beyond Placement Intake Form

Beyond Placement Therapeutic Support Group

Welcome to Beyond Placement therapeutic support group! This form helps us better understand your background and ensures we can provide you with the best possible support. All information is confidential and will only be shared with the group facilitator and clinical supervisor as needed for your care.

Intake Form

Personal Information

First Name *
Last Name *
Country
Address Line 1 *
City *
State/Province *
Postal Code *
What is your date of birth?
First Name *
Last Name *

Demographic Information

Race/Ethnicity (Please check all that apply):
What are your pronouns:
What is the highest level of education you have completed?
Relationship Status
Current Employment Status

Insurance and Financial Information

Do you have health insurance?
Are you eligible for or currently receiving Medicaid?
Primary Insurance (if applicabale)

Mental Health Information

Have you ever been diagnosed with a mental health condition?
Are you currently taking any medications for mental health?
If yes, are you working with a psychiatrist or primary care doctor for medication management?

Adoption Information

When did you place your child(ren) for adoption? (Check all that apply)
(Name of Agency/Attorney/DCFS/Foster, Contact Name, Phone/Email)

Child 1:

How would you describe your placement currently?
Placement type:
Is this a transracial placement?
Current contact level:

Child 2:

How would you describe your placement currently?
Placement type:
Is this a transracial placement?
Current contact level:

Additional Information

Primary language spoken at home:
Do you need any accommodations for group participation?

Consent & Signature

I understand that:

  • This information will be kept confidential and only shared with the group facilitator and clinical supervisor as needed for my care
  • I can update or change any of this information at any time
  • Providing this information is voluntary, but helps ensure I receive appropriate support
  • I have the right to ask questions about how this information will be used
  • If the facilitator believes I am in crisis and may pose a danger to myself or others, they reserve the right to contact my emergency contact and/or emergency services to ensure my safety
  • I understand the limits of confidentiality and that my safety takes priority
First Name *
Last Name *
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