Dr Adrian Hekel
GP-Psychology BSc(Hons), MBBS
Banyo Clinic
183 Tufnell Road BANYO QLD 4014
email:
dradrianhekel@gmail.com
INTAKE FORM FOR TRAUMA COACHING SESSIONS
PLEASE COMPLETE THIS FORM USING BLOCK LETTERS
Full Name:
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Date of Birth:
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Mobile:
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Format: (000) 000-0000.
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Email:
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Next of Kin / Emergency Contact:
Emergency Contact Email:
Place of Birth:
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Cultural Background:
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Languages spoken at home:
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Gender:
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Relationship Status:
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Who Referred / Recommended You?
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What is your overarching intention in participating in these sessions?
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What are the stories/ experiences of your life that first come to mind as useful for me to know about you?
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Have you done any 'inner work' or therapy in your past, either 1 on 1 or in a group? If so, what did you do and how did it benefit you?
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Please tell me a little about your social circle, friends, family, colleagues, etc. Who do you spend time connecting with, and how does this sustain and/or support you?
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What significant life changes or stressful events have you experienced recently?
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Do you have any significant mental health, trauma, substance use or physical health issues that you feel are important to mention?
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