dgaplogo.gif (3465 bytes)


Bob Bennett, M.D.,CGP,FAPA
Melissa Black, Ph.D.
Dale C. Godby, Ph.D.,CGP,ABPP
Myrna Little, Ph.D.,CGP

972-392-4155


Matching Patients in Groups

Date:  ____________________________


Dear Group Therapist:

It would be helpful, in matching potential referrals to your groups, to have a picture of a current composition and characteristics.  (We plan to repeat this inquiry every six months.)

  1. Group time(s)


  
  1. Approximate age range


  
  1. Analytic (0-4)


  
  1. Supportive (0-4)

 

  
  1. Regressive potential (0-4)


  
  1. Inhibited (0-4)

 

  
  1. Confrontational (0-4)

 

  
  1. Speed (0-4)


  
  1. Nature of any recent crisis: e.g., drop-outs, problem patients

 

  
  1. Special features of group:


  

(0-4) - absent to high

 

bbar.gif (2270 bytes)