EMPLOYEE PWCC INTAKE – New Jersey Anger Management Group

Email Address

Name of Your Direct Supervisor

Who referred you to this program? *

Were you given a specific reason for the referral? *

Yes No Partially

If yes, what reason were you given?

Do you agree with the reason you were referred? *

Yes, I agree Partially agree No, I disagree Unsure

Is this referral connected to a specific incident? *

Yes No — ongoing pattern No — preventive / proactive Unsure

If connected to a specific incident, briefly describe what happened:

Are you currently experiencing any particular issues at work? *

Yes No Somewhat

If yes, please describe the issues you’re experiencing:

Are there any areas of concern from YOUR perspective about your workplace conduct? *

Are you having a problem with any particular employee(s)? *

Yes No

If yes, please describe the situation (you may use first names only):

Do you feel your work environment contributes to your stress or conduct challenges? *

Yes, significantly Yes, somewhat No Unsure

If yes, what about your work environment contributes?

Have you previously received any disciplinary action at this employer? *

Have you experienced similar conduct issues at previous employers?

No — first time Yes, similar issues Prefer not to say

Have you ever completed an anger management or conduct program before?

No Yes

How would you rate your ability to manage anger or frustration at work?

How would you rate your communication skills during conflict?

How would you rate your ability to handle workplace stress?

How would you rate your ability to accept feedback or criticism professionally?

How would you rate your ability to de-escalate tense situations?

Which of the following topics would you like to focus on during your program?

Are there personal factors outside of work that may be contributing to workplace stress or conduct challenges?

Is there anything else you’d like your facilitator to know before your program begins?

What is your primary goal for completing this program? *

Satisfy my employer’s requirement Genuinely improve my workplace skills Both — satisfy the requirement AND improve Unsure

What would success look like for you after completing this program?

On a scale of 1-10, how committed are you to making the most of this program?

Professional Workplace Conduct Course Intake Form

Section 1 — Personal Information

Section 2 — Referral Information

Section 3 — Workplace Self-Assessment

Section 4 — Conduct History

Section 5 — Skills & Awareness Assessment

Section 6 — Program Focus Areas

Section 7 — Personal Factors

Section 8 — Your Goals

✓ Intake Submitted Successfully

Comments

Leave a Reply Cancel reply