Information shared during the intake interview is confidential. Intake and attendance of the confidential support group are completely voluntary.


General Information



Name:*
Address:*
Phone:
-
E-mail:*
Best Way to Contact You:
Who do you live with?
Emergency Contact:*
Relation:*
Emergency Contact Phone:*
-
How did you hear about SAGA?
Schooling:
Educational Goals:
Preferred Activities:
Work:
Religion/ Spirituality:

Gender and Sexuality



Gender Identity:

Scale of Attraction

Rate the following genders based on your level of attraction to each (1=Less attracted to, 10=More attracted to)

Male:
1
2
3
4
5
6
7
8
9
10
Female:
1
2
3
4
5
6
7
8
9
10
Transgender:
1
2
3
4
5
6
7
8
9
10
Additional Comments:
Are you currently sexually active?
Have you historically been sexually active?
Do you have any safety concerns?
Are you out?
To whom?

Health



Health Issues:
Medication:
HIV Tested:
Date Tested:
Result of HIV Test:
Have you ever attempted suicide or self-injured?
Have you used drugs or alcohol?
Are you currently seeking counseling or have you previously?

Group Expectations



Key issues you would like to have addressed or met:
Questions:
I am human: