POWERS BENZO COACHING
New Client Intake Form. HIPPA Compliant & Protected.
Name
First Name
Last Name
Today's Date
Contact Number
-
Area Code
Phone Number
Contact Email
example@example.com
Age?
Country of Residence?
What country do you live in?
State of Residence?
What State do you live in?
How long have you been on benzodiazepines?
Reason Benzodiazepine was prescribed?
General Anxiety Disorder
Depression
Post Traumatic Stress Disorder
Sleep
Muscle Relaxer
OCD
Stress
Post Heart Procedure
Panic Disorder
Health Anxiety
Other
Currently Prescribed Benzodiazepine
Valium (Diazepam)
Xanax (Alprazolam)
Klonopin (Clonazepam)
Librium (Chlordiazepoxide)
Ativan (Lorazepam)
Restoril (Temazepam)
Halcion (Triazolam)
Other
Current Benzodiazepine Dose?
Usual Benzodiazepine Dose?
Usual dose before tapering?
Other psychiatric medications? (I.e., SSRI's, Gabapentin, etc.)
How long have you been tapering?
If already tapered, how long have you been off of benzodiazepines?
If already tapered, what benzodiazepine were you on and average daily dose?
What are you goals for coaching?
What symptoms do you struggle with the most?
No Symptoms
Minor Symptoms
Moderate Symptoms
Severe Symptoms
Anxiety
Depression
Panic Attacks
Rumination
Sleep
Akathisia
Difficulty Breathing
Nerve Pain
Depersonalization
Suicidal Thoughts
Fatigue
How often do you ruminate on:
Never
Sometimes
Often
Always
Not fully healing
Having brain damage
Getting worst
Getting stuck in taper
Trauma from doctor
Trauma from withdrawal
Symptoms
Not sleeping
Physical Pain
Health Anxiety
Reinstating on benzo
The things I've lost
If symptoms are dangerous
How hopeless you feel
How angry you are
Doing permanent damage
Poor support in your life
How foolish you were
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, but with some anxiety
Yes, but with a lot of anxiety
No, I have panic attacks
Do you have a therapist?
Yes
No
Seeking
I understand that David Powers offers Coaching and NOT Counseling 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!
Signature
Submit
Should be Empty: