Group Participation Intake Form

Todays Date

MonthDayYear
Group Participant Registration Form

For all groups facilitated by the N'Spired Network of providers in partnership with N'Spired By Achievement Family Services & Solutions, LLC.
Participant Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone*

Area CodePhone Number
Cell Phone*

Area CodePhone Number
Participant E-Mail*
What groups are you interested in participating in?

COVID-19: Coaching through the AnxietyThe Black Man: Dealing with everyday SocietyRelationships: Do they love me as much as I love them?Entrepreneurial Coaching: How do I take things to the next level and take that leap?
What times of day are more beneficial for you?

Early mornings (before 10am)Late mornings (10am-12noon)Midday (12noon - 4pm)Early evenings (4pm-7pm)Late evenings (7pm-10pm)
Which days work better for you?

MondaysTuesdaysWednesdaysThursdaysFridaysSaturdaysSundays
Occupation Category*
Current Occupation
Emergency Contact*
Relationship to Patient*
Emergency Contact Phone Number*

Area CodePhone Number
Program Information
Why are you interested in participating in the group?*
Present Health
Are you currently receiving any coaching or counseling therapy? *
If YES, What's the name of your service provider?
Their email address?
Phone Number of provider?

Area CodePhone Number
Phone Number of provider?

Area CodePhone Number
How would you rate your current mental health?*
Over the last 1-2 months has your mental health changed?*
Are you currently under the care of Primary Care or Pediatric Care Physician? *
If YES, What's the name of your service provider?
Their email address?
How would you rate your current physical health?*
Over the last 1-2 months has your physical health changed?*
Do you take any nonprescription drugs, vitamins and/or any other supplements? Please list them.*
Are you currently under the care of a family physician or any other health professional? If yes, include details.*
Do you currently take medication and/or receive medical treatment for your health condition(s)? If so, include all medications, treatments, and dosages.*
Do you have any past medical history or problems (i.e.. illness, trauma, emotional stress, addictions, drug abuse, or anything else that will help us clearly understand your health condition)?*
Is there a family history of the health problem(s) listed above? If yes, please specify.*

Fill in as appropriate

	Child	Myself	Father	Mother	Brother(s)	Sister(s)	Spouse	Other
Age (if living)
Age (at death)
Cause of death
Anemia
Cancer
Diabetes
Epilepsy
Glaucoma
Hearth Disease
High Blood Pressure
Hay Fever
Hives
Kidney disease
Mental illness
Rheumatoid arthritis
Tuberculosis
Syphilis
Stroke
Other

Any other family illnesses or concerns? If yes, please specify.*
Health as a child:*
Childhood illnesses:*

German measlesMeaslesMumpsBronchial problemsScarlet feverDiphtheriaOther
Immunizations/vaccinations:*

SmallpoxPolioTyphoidMumpsTetanusInfluenzaOther
Have you ever experienced a reaction to vaccination(s)? If yes, please specify.*
Daily Routine (dinacharya)
Do you get up early?

YesNo
At what time?*

:HourMinutesAM/PM Option
Do you go to bed early?

YesNo
At what time?*

:HourMinutesAM/PM Option
Do you sleep during the day?

YesNo
At what time?*

:HourMinutesAM/PM Option
How do you generally feel when you wake up in the morning?*
In what direction does your head point during sleep?*
How would you describe your experience of sleep?*
What position do you sleep in?*
How regularly do you follow your ideal routine (i.e., go to bed early, eat meals on time, exercise regularly)?*
Describe your bowel movements.*
Other, please specify
Bowel nature:*
Bowel movement associated with (choose those that apply).*

PainBloodMucousFoul SmellOther
Do you delay or suppress any of the following?

SleepBowel movementsGasUrinationYawningBurpingThirstBreathingSemenHungerSneezingTears
Do you travel often? *

YesNo
Do you self-massage with oil daily?*

YesNo
Excercise
How often do you excercise?*
What type of exercise do you do?*
How long do you excercise each time?*
Rate the intensity of your excercise.*
Eating Habits

Choose the answer that best describes your eating habits*

	Daily	Weekly	Monthly	Never
Grains/cereals
Vegetables
Fruits
Dairy
Eggs
Poultry
Meat (beef, pork, etc.)
Seafood
Sugar/Honey
Desserts
Juices

Describe what you typically eat
Breakfast*
Lunch*
Dinner*
Snack*
Do you eat between meals?*

YesNo
Do you eat meals at regular times?*

YesNo
Which is your biggest meal?*
Rate your digestion.*
How much water do you drink per day?*
Indicate your eating habits.*
Describe your diet.*

VeganLacto-vegetarianLacto-ovo vegetarianOther
If you are a nonvegetarian, please indicate the proteins you eat.

BeefPorkChickenTurkeySeafoodEggsOther
Indicate which best describes your sense of taste (if any).*
What taste(s) do you like to crave?*

SweetSaltySourBitterHot/SpicyStarchesOily
Are there particular foods that create discomfort when you eat them?*

SweetSaltySourBitterAstringentDairy Products (including cheese)
Miscellaneous
Do you practice any type of meditation? If yes, please explain.*
Do you practice yoga? If yes, please explain.*
Which type of weather makes you feel most uncomfortable?*
Are you allergic to any substances?*

FoodPollenDustOther
If you smoke cigarettes (or other substances), how many do you smoke per day?
How often do you drink alchohol?*
How much at at time?
How often do you drink caffeinated beverages?*
How would you rate your usual energy level?*
Do you experience any of the following?*

DepressionAnxietyFear or panicLonelinessWorryHigh stress levelAngerLack of memoryLight-HeadednessLack of energySuicidal thoughts or attemptsIrritation
Social History

Select the best answer for the the questions asked.*

	Excellent	Good	Fair	Poor
How are your family relationships?
How is your social life?
How is your mental health?
How is your career?
How purposeful is your life?
Rate your spiritual life.

As a child, did you experience any abuse or trauma?*

YesNo
Type of abuse:*

EmotionalPhysicalSexualVerbalOther
For Men Only
Please indicate which of the following areas are troublesome (if any).

HerniasSexual difficultyUrinationErection problemLibidoBirth controlProstrate problemsDischarge or soresVenereal diseaseTesticular masses
For Women Only
Age menses began:
Which of the following describes your menstruation?
How many days does your menstrual period last?

1-4 days5-7 daysMore than 1 weekIrregular throughout the monthOther
How is your menstrual flow?
Do you have any associated symptoms (before or during menstruation?

NonePainFluid retentionMigraineDepressionAcneTensionNightmaresFrustrationLoneliness
Do you have any discharge outside of your menstrual period?

YesNo
Do you ever experience pain during intercourse?

YesNo
Are you pregnant now?

YesNoI don't know
Do you have any sexual difficulties?

YesNo
If yes, please explain.
Do you take contraceptive pills or use other forms of birth control?

YesNo
If yes, please explain.
Number of previous pregnancies.
Do you have any history of abortion, miscarriage, or problems related to pregnancy or labor? If yes, explain.
How many children do you have?
How old are your children?
Do you breast self-exam regularly?

YesNo
Do you experience any of the following?

Pain or tendernessLumpsNipple dischargeOther
Other comments
I understand that this form is completed for the purpose of participation in an educational group (be it coaching or therapeutic) for the purpose of creating an online or in person community of support helping me improve my personal wellbeing, develop insight, and/or cope with changes in life. I understand this does not include medical diagnoses or treatment and is not a substitute for medical care, 1-on-1 mental health therapy or an agreement for ongoing care post group completion.

I also understand that upon pressing submit, I may receive coorespondence regarding times available for the group as well as other recommendations deemed beneficial based on the information provided above.
Client Signature*

Clear
By signing you agree to the conditions stated above
Should be Empty:

Group Participant Registration Form

Program Information

Present Health

Daily Routine (dinacharya)

Excercise

Eating Habits

Describe what you typically eat

Miscellaneous

Social History

For Men Only

For Women Only