Course Registration Form

Client Registration Form

Fill out the form carefully for registration
Client Name

First NameMiddle NameLast Name
Pronouns
Ex: She/They
Birth Date

MonthDayYear
Gender
City/State/Country of Residence

Time Zone

CityState / Province

Postal / Zip Code
E-mail
example@example.com
Mobile Number
Format: (000) 000-0000.
Emergency Contact

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to you
Ex: Romantic Partner
Your Occupation/ Profession
Do you have any children?

YesNoOther
Relationship Status

SingleIn PartnershipMarriedDivorcedPolyamorous RelationshipPrefer not to answer
Service(s) you are inquiring about
Please select all that apply
What are you seeking support for at this time? Please provide a brief description at the level of your comfort.
NOTE: If you are inquiring about Corporate Retreats, please stop here and refer to Retreat Registration form.
Please provide a list of all mental health and/or wellness services that you have previously participated in. Include dates
Ex: 1- Attended therapy and EMDR from 2000-2005. It was somewhat helpful.
Are you currently on any medications?

YesNeverRecently went off medsPrefer not to disclose
Any history with substance abuse/ other forms of addiction? Please describe below
If you answered "Yes" or "Recently went off medications" please provide details below
Ex: Clonazepam 1 mg as needed, taking since 2010
Do you experience suicidal ideation?

Currently battling suicidal thoughtsI have in the past, but not at the momentNever experienced suicidal thoughtsPrefer not to answer
Any history of Mental Illness or addiction in the family?
Ex: Brother diagnosed with BPD and Anxiety
Any Medical Health Conditions?
Ex: PCOS and IBS
What qualities do you value in a mental health practitioner?
Have you ever attempted suicide?

Yes, onceYes, multiple timesNoPrefer not to answer
What are some of your hopes and aspirations in life?
Have you experienced events that you consider traumatic, and have left a significant impact on your life since their occurrence? (please provide as much as you feel comfortable sharing)
Do you have experience with meditation, mindfulness, or yoga practices? please describe below.
Do you have any specific accommodation request that you would like me to be aware of before our consultation call?
If you have not done so already, please provide your time zone and preferred days/times for our call.
Please note that Sarah's therapeutic approach is based in holistic and wellness practices, if you find this to be great news, then you are a great fit!

Thank you for taking the time to fill out this form. Someone from our team will reach out to you for scheduling and any related information within a week.
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Client Registration Form

NOTE: If you are inquiring about Corporate Retreats, please stop here and refer to Retreat Registration form.

Please note that Sarah's therapeutic approach is based in holistic and wellness practices, if you find this to be great news, then you are a great fit!