Adult Intake and History Form

"Trauma is not what happens to us, but what we hold inside in the absence of an empathetic witness"

--Peter Levine
Darla Bruno, Integrative Wellness Coach, SEP

Sharing information about yourself will help me understand why you have arrived at the work of SE and to better serve you. Please answer the following questions before your first appointment.

But PLEASE NOTE this is a long form intended to have you provide as much information as possible. This is not required. Filling out this form a little at a time is suggested. If it feels like too much at any point, overwhelming or distressing, we can do this together, over time, as we get to know one another.

Please check in with yourself and only answer questions that you wish to share and only fill this out if you feel okay doing so.

Thank you.
Name
Date

MonthDayYear
Date
1. What are the main concerns you have for seeking help at this time? Please include your symptoms, pain, illness, injuries, onset, upsets, losses, functional problems, fears, worries, etc.
2. Please describe what you feel in your body and where you feel it (i.e., tension in lower back, constriction in chest, tight jaw, pain in heels, etc)
3. What would you like to achieve from Somatic Experiencing and our work together? Please list some of your goals.
1.
2.
3.
4.
4. List the medications, supplements, remedies, and herbs you take.
5. List therapies and treatments you participate in (physical therapy, chiropractic, massage, etc).
6. Do you have any allergies?
If yes, to what?
7. Past medical history (include dates) (major or ongoing illnesses, surgeries, hospitalizations, accidents, injuries)
8. Have you experienced any of the following? (please check)

Motor Vehicle AccidentConcussionPhysical AssaultSexual AssaultSurgeryGeneral AnesthesiaAbuse (emotional or physical or otherwise)Witness to horrific eventNatural disasterWar/Military actionAnimal attackComplications with pregnancy or birthEarly developmental traumaRelational traumaGenerational traumaSudden loss of close friend or family
List any other traumatic experiences or use this space to provide more information about the above. Please note: A traumatic event is more about the person's experience than the event itself. While the list above are common events that cause trauma, everyone responds differently.
9. List your resources: places, people, pets, experiences, and so forth that settle you, make you feel more like yourself, or bring about pleasant feelings.
10. Do you exercise or do movement practices?

YesNoNot often
If, so what and how often?
11. Do you have a spiritual practice?

YesNo
If yes, please feel free to share more
12. Do you smoke tobacco

CigaretteCigarPipeNo
13. Do you use marijauna or other recreational drugs in any form? If so, please share more below.
14. How much alcohol do you drink, if any?

Beer, 1-4 per weekBeer, more than 4 per weekWine, 1-4 glasses per weekWine, more than 4 per weekOther alcohol, 1-4 per weekOther alcohol, more than 4 per week
15. Have you ever struggled with addiction?

YesNo
If yes, please describe - how many years? Active? How many years sober/in recovery?
16. What are you eating habits like?
Typical breakfast
Typical lunch
Typical Dinner
Typical Snacks
Typical beverages (include water, coffee, tea, soda, etc, and how many cups per day)
17. How is your sleep?
What is your average bedtime? How many hours per night of sleep?
18. Have you ever had a problem with eating or an eating disorder?
Yes (Feel free to specify type)
No
19. Do you remember your dreams?
Yes
Has there been a theme to them recently? What is it?
No
20a. What are the stressors in your life right now? Please list them here.
20b. How do you reduce your stress?
21. Briefly describe your present living situation
22. Have you experienced any anxiety or depression lately?

AnxietyDepressionBothFeeling more shut-down, dissociated
Please describe in further detail.
23. Have you recently or in the past thought about suicide?

YesNo
If yes, please share when.
Have you ever attempted suicide.

YesNo
If yes, please share when
24. What do you do that makes you feel good?
25. Have you ever been, or are you presently in counseling or psychotherapy?
Yes
Other therapeutic work
Describe why you went and your experience
No
26. What is your occupation?
Do you enjoy your work? Yes or no here.
Describe why or why not
27. What kind of support system do you have?

FamilyFriendsPartnerReligious or spiritual communityTherepeuticOnline
Other support, please describe
28. Relationship

SingleMarriedIn a relationshipDivorced
Other, please describe
Spouses/Partner's Name
If married, how many years.
If divorced, when was your divorce
Do you have children?

YesNo
If yes, how many and what are their ages.
29. Family History

Please share if your family member is alive. What conditions they might experience. Or if they have passed.
Mother
Father
Sisters
Brothers
30. Briefly describe your childhood (joyful, unstable, siblings, adopted/fostered, uneventful, etc), in particular in relationship to your family of origin.
31. What do you enjoy doing in your life?
Is there anything else you would like me to know right now? (Please use the space below.
Should be Empty: