Trauma Informed Care
healingbyreleasing.com
Full Legal Name
By what name shall your Coach address you?
Sex
Age
Date of Birth
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Month
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Day
Year
Date
Email address
example@example.com
Relationship Status
Please Select
Single
Married
Divorced
Separated
Widowed
Other
Home Address + Country
Occupation
Best phone number to reach you
Emergency Contact Phone Number
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:
Bipolar Disorder
Depression
Autism
Schizophrenia
ADHD
PTSD
C-PTSD
Anxiety
Panic Attacks
Alcohol Abuse
Suicide
Narcissistic Personality Disorder (NPD)
Has anyone in your family had a history of any of the above? Or a condition not mentioned? Please Explain
Current Symptoms
Depressed mood
Excessive worry
Impulsivity
Insomnia
Nightmares
Avoidance
Increased libido
Decreased libido
Brain fog
Forgetfulness
Suspiciousness
Excessive energy
Increased irritability
Crying spells
Unable to enjoy activities
Racing thoughts
Anxiety attacks
Increased risky behaviors
Hallucinations
Loss of interest
Desire to sleep more than 8 hours a night
Change in appetite
Isolation
Fatigue
Lack of joy
Replaying scenarios over and over in head
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
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