Client Intake
Please fill out prior to your first session or if it has been longer than one year since we have seen you last.
Todays date
*
-
Month
-
Day
Year
Date
Name:
*
First Name
Last Name
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email:
*
example@example.com
Phone Number: (one where you can receive notifications)
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth:
*
-
Month
-
Day
Year
Date
Age:
*
Identification:
Female
Male
Nonbinary
Opt out
Preferred pronouns
Status:
Single
Married/Partner
Divorced
Child (13 or under)
If client is a child, please list who will be responsible for bringing them to their appointment and their phone number.
Emergency Contact / Relation:
Emergency Contact Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Names and ages of the people who live with you:
Are you currently seeing a therapist:
*
Yes
No
Therapist Name and number:
Have you done neurofeedback before
Yes
No
If you have done neurofeedback before, please tell us where you did sessions and about your experience:
Have you had COVID-19 which resulted in experiencing Long Covid?
Yes
No
Tell us about any head injury, concussion or TBI you have experienced over your lifetime:
What health issues either chronic or new are you managing currently?
*
Exercise (what type and how many times a week):
*
List any medications and supplements you are currently taking:
(Dose is not necessary)
What types of past or current life stressors are you managing?
*
Share the amount of detail you feel comfortable with.
Anything else you'd like us to be aware of prior to your appointment?
How did you find us?
*
My therapist
My friend
My doctor
My naturopath
Internet search
Other
List who referred you:
If referred by a medical doctor or therapist please fill out our Referral Authorization form.
Submit
Should be Empty: