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

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)

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?

If, so what and how often?

11. Do you have a spiritual practice?

If yes, please feel free to share more

12. Do you smoke tobacco

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?

15. Have you ever struggled with addiction?

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?

Please describe in further detail.

23. Have you recently or in the past thought about suicide?

If yes, please share when.

Have you ever attempted suicide.

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?

Other support, please describe

28. Relationship

Other, please describe

Spouses/Partner's Name

If married, how many years.

If divorced, when was your divorce

Do you have children?

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.