Listening • Remembering • Becoming

New Client Intake

First Name *

Last Name *

Date of birth *

Birth Place - City, State, Country *

Birth Time

Email *

Phone *

Mailing Address *

City *

State *

Postal code *

Country

Emergency Contact *

Emergency Contact Phone *

Relationship

Spouse / Partner

Parent

Friend

Other

Are you currently receiving psychological services, professional counseling, psychiatric services, and/or any other mental health services?

*

Yes

No

Are you currently taking any psychiatric prescription medication?

*

Yes

No

If so, what medications are you taking?
Please list dosages and frequency.

Are you currently in a romantic relationship? *

Yes

No

If yes, how long have you been in this relationship?

On a scale from 1-10 (10 being great), how would you rate the quality of your relationship?

In the last year, have you had any major life changes (e.g. new job, moving, illness, relationship change, etc.)?

Do you practice a religion? *

Yes

No

If yes, what is your faith?

Are you currently employed? *

Yes

No

If yes, who is your employer?

What is your position?

Are you happy in your current position?

Yes

No

Does your work make you stressed?

Yes

No

If yes, what are your work-related stressors?

The following is to provide information about your family history. Please mark each as yes or no.

Depression *

Yes

No

If yes, please indicate the family member(s) affected.

Suicide *

Yes

No

If yes, please indicate the family member(s)affected.

Bipolar Disorder *

Yes

No

If yes, please indicate the family member(s) affected.

Panic Attacks *

Yes

No

If yes, please indicate the family member(s) affected.

Alcohol/Substance Abuse *

Yes

No

If yes, please indicate the family member(s) affected.

Eating Disorder *

Yes

No

If yes, please indicate the family member(s) affected.

Trauma History *

Yes

No

If yes, please indicate the family member(s) affected.

Domestic Violence *

Yes

No

If yes, please indicate the family member(s) affected.

Sexual Abuse *

Yes

No

If yes, please indicate the family member(s) affected.

Obsessive Compulsive Behavior *

Yes

No

If yes, please indicate the family member(s) affected.

Schizophrenia *

Yes

No

If yes, please indicate the family member(s) affected.

List your strengths and what you like most about yourself: *

List areas you feel you need to develop: *

What are some ways you cope with life obstacles and stress? *

What are your goals for our session(s) what would you like to accomplish? *

What is the amount of time you are willing to commit to your healing? *

Less than 3 months, looking for a quick fix

About 6 months, I know this will take time

12+ months or as long as it takes

Listening • Remembering • Becoming

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Spiritual healing is not a substitute for allopathic medicine.
If you have a health concern, you should always consult a physician.

Listening • Remembering • Becoming

Listening • Remembering • Becoming

New Client Intake

Listening • Remembering • Becoming

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