Intake form

Trauma Informed Care

healingbyreleasing.com
Full Legal Name
By what name shall your Coach address you?
Sex
Age
Date of Birth

MonthDayYear
Date
Email address
example@example.com
Relationship Status
Home Address + Country
Occupation
Best phone number to reach you
Format: (000) 000-0000.
Emergency Contact Phone Number
Format: (000) 000-0000.
Emergency Contact Name and Relation
Do you have any children? If so, how many? Age, Gender and anything else you would like to share about them
Are you currently under professional psychiatric care?
Name of Therapist and Specialty (optional)
Therapist Phone Number (optional)
Have you ever been clinically diagnosed with or treated for:
Has anyone in your family had a history of any of the above? Or a condition not mentioned? Please Explain
Current Symptoms

Other
Have you ever had a problem with Addiction? If yes, was it treated?
Have you been convicted of a crime within the past 10 years?
Have you ever been convicted of a sexual offense?
Have you consulted with a life coach or trauma therapist in the past? If so, which one and what did you like and dislike about the process?
Have you ever worked with a holistic wellness practitioner?
Have you ever recieved Bioresonance Treatment?
Are you interested in Couples Sessions or Family Sessions?
Are you interested in incorporating a faith/belief system in your treatment protocol
If yes, please share your belief system above
What brings you here today?
What is missing in your life right now?
What emotions would you like to experience more of?
Please list 1-3 goals you would like to accomplish
What has prevented you from accomplishing those goals?
What do you hope to have accomplished by the end of our session(s) together?
What would be the most significant success you could hope for from our meeting?
Additional thoughts, concerns or requests
Who were you referred by?
I hereby declare that the information I provide is true and correct
Today's Date:

MonthDayYear
Date
Signature
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Trauma Informed Care