POWERS BENZO COACHING
New Client Intake Form. HIPPA Compliant & Protected.
Full Name
First Name
Last Name
Age?
Contact Email
example@example.com
Contact Number
Area Code
Phone Number
Country of Residence?
What country do you live in?
State of Residence?
What State do you live in?
Are you currently tapering, post-withdrawal, or still taking benzodiazepines?
Currently tapering
Fully off (post-withdrawal)
Still taking benzodiazepines
Other
What benzodiazepine are you currently taking?
Please Select
Valium
Xanax
Klonopin
Ativan
Librium
Temazepam
Other
Off benzos
Usual dose of benzo?
Current dose of benzo?
How long have you been on benzos?
If tapering, how long have you been tapering?
If already tapered, how long have you been off of benzodiazepines?
What other medication(s) were/are you on, and for how long?
(Include dosage history if possible)
Have you taken any other psychiatric medications (SSRIs, SNRIs, etc.)?
(Include dosage history if possible)
Have you ever been formally diagnosed with any mental health conditions?
Generalized Anxiety Disorder (GAD)
Panic Disorder
OCD
Depression
PTSD
Health Anxiety / Hypochondria
Insomnia
Other
Have you ever been diagnosed with or suspect you have any neurological or autoimmune conditions?
(E.g., POTS, Dysautonomia, Lyme disease, Fibromyalgia, etc.)
What are your TOP THREE most difficult symptoms right now?
(E.g., anxiety, depression, intrusive thoughts, insomnia, fatigue, derealization, etc.)
How physically active are you?
A lots of daily movement
Some daily movement
Little daily movement
Symptoms are too bad!
How often do you get out of the house?
Multiple times a day
At least once a day
A few times a week
Once a week
Don't leave very often
Can you operate a vehicle?
Yes, easily
Yes, but with difficulty
No
Do you have a therapist?
Yes
No
Seeking
Do you struggle with obsessive rumination?
Yes
No
Unsure
How is your sleep currently?
Normalizing
Poor but manageable
Severe Insomnia
How would you describe your energy levels?
Normal
Some fatigue
Severe fatigue (struggle with daily tasks)
Do you experience any of the following neurological symptoms?
Tinnitus
Burning skin / nerve pain
Internal vibrations / tremors
Akathesia
Cognitive issues (brain fog, memory problems, difficulty focusing)
Sensory hypersensitivity (light/sound sensitivity)
How do you currently cope with withdrawal symptoms?
Mindfulness or meditation
Exercise / movement
Distraction techniques (work, hobbies, etc.)
Seeking reassurance (forums, Youtube, constant symptom-checking)
Avoidance (isolating, avoiding activities due to fear)
Other (please list)
Do you feel your relationship with fear is one of your biggest obstacles?
Yes
No
Unsure
Do you engage in avoidance behaviors (avoiding places, activities, sensations, etc.) due to fear?
Frequently
Sometimes
Rarely
Never
How often do you check withdrawal forums or seek reassurance?
Daily
Multiple times per week
Occasionally
Rarely or never
What are your top 3 goals for coaching?
(E.g., managing anxiety, improving sleep, breaking avoidance, calming limbic system, etc.)
Are you looking for:
A structured, step-by-step program (North Star)
Personalized 1-on-1 guidance & deeper coaching
A mix of both
How committed are you to actively working on your recovery?
1
2
3
4
5
Not ready
Fully committed & willing to challenge myself
1 is Not ready, 5 is Fully committed & willing to challenge myself
Do you have any major concerns or expectations for coaching?
(Please list anything you feel is important for me to know.)
Is there anything you feel is holding you back from recovery?
(E.g., fear, lack of motivation, financial stress, etc.)
How did you hear about this coaching program?
(Youtube, referral, website, forum, etc.)
I understand that Coach Powers offers Coaching and NOT Therapy.
Yes
No
What's the difference?
I understand that I should ALWAYS inform my doctor(s) of the work I do in benzo coaching and that their medical orders are paramount.
Yes, of course
No, they won't understand
I don't have a medical doctor helping me taper!
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