New Client Intake Form

New Client Intake Form

Before we begin our work together, I ask that you complete this New Patient Intake Form. It may take a bit of time to fill out, but your thoughtful responses will help me understand your background and guide our first session. Please reach out if you have any questions: therootcause.rh@gmail.com.
Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.

Personal Details
Age*
Gender*
Are you left or right handed?*
Time of Birth*

MonthDayYear
Date
Hour MinutesAM/PM Option
Place of Birth*
Mother's Date of Birth*

MonthDayYear
Date
Father's Date of Birth*

MonthDayYear
Date
Date of Parent's Wedding

MonthDayYear
If your parents were not married or the date is unknown, leave blank

Personal Details: Family and Marriage
How old were you when you became totally independent from your parents? (food, shelter, and money)*
Year and month of being independent*
What is your current marital status? *
Length of time married
Do you have any previous marriages?
Number of previous marriages
Additional notes
Please indicate any additional pertinent information on marriage you would like to provide
How many children do you have? *
Children: Age and date of birth
Please list each child on a separate line
Your rank in the family
Include stillborn and aborted (if known)
Did your mother have any miscarriages? If yes, how many?*
Have you had any miscarriages? If yes, how many?*
Did your mother have any abortions? If yes, how many?*
Have you had any abortions? If yes, how many?*
What is your highest level of education completion?
What is your main concern? Why are you interested in Recall Healing? Please include any diagnosis.*

Your Life Timeline

Please list the major events of your life (dramatic events, trauma, shocks, fears, etc.) starting with the Present and working your way back to Birth. Write down everything meaningful you can remember in each category (Age, Date, Event, Feelings) in the following order:

Example

Age	Date	Event	Feelings
46y 10m	Aug 10, 2005	Car Accident	Fear, thoughts of death
40y 02m	Nov 06, 1999	Separation	Despair, hopeless, unworthy
16y 11m	Oct 20, 1972	Parents divorce	Powerless, sad, angry, etc.
13y 02m	Nov 10, 1972	Elder brother died	Sad, angry, rage, hurt

Timeline*

Uncovering Life’s Challenges: Your Emotional Journey

In this section, we delve into some of the most impactful moments in your life—events that may have shaped your emotional and physical well-being. Reflect on experiences such as the greatest negative shock you’ve faced, sudden traumatic events, deep fears, and regrets. We also invite you to share any strong emotions you’ve felt, whether from intense annoyances, remorse, or secrets you’ve kept hidden. Your insights into these moments, including those leading up to the onset of any illness, will help us better understand your journey and support your healing process.
The greatest negative shock of your life*
It can be the one that preceded your illness or another one
Date at the beginning of your illness

MonthDayYear
Date
Age at the beginning of your illness
Did you experience a sudden shock or the conclusion of a major event or situation—whether positive or negative—in the months or year leading up to the start of your illness?*
Describe any fears or frights you have experienced, whether they were intense, chronic, or particularly fierce*
Have you experienced very strong annoyances or vexations that were accompanied by a combination of anger and sorrow?*
Have you felt deep remorse or regrets, where you wished you had done something differently?*
Have you experienced a sudden traumatic event, such as the unexpected death of a loved one?*
Have you ever kept a heavy secret that you’ve never shared with anyone?*
Do you have any additional comments about significant conflicts you’ve experienced that you would like to share?

Before You Were Born: Your Parents’ Journey

In this section, we’d like to explore the time when your mother was pregnant with you. Reflect on what was happening in your parents’ lives during that period—whether it was personal challenges, significant events, or even broader circumstances like natural disasters or major societal changes. Understanding these moments can provide valuable insight into your early life experiences.
What do you know about what was happening in your mother’s life at the time of your conception?*
What about during her pregnancy with you?*
And during the first year of your life, leading up to your first birthday?*
Describe your family tree

As far as you can remember, going back if possible, 3 or 4 generations on both your father’s and your mother’s sides of the family (you and siblings, parents, grandparents, and great grandparents). Give any information you might have about any miscarriages or abortions, as well as about illnesses, causes of death, dates of birth and death, and particular characteristics of their lives. (This work is always very useful.)
Immediate family (you and siblings, parents)*
Provide information about you, your siblings, and your parents. Include details such as any miscarriages or abortions, illnesses, causes of death, dates of birth and death, and any significant characteristics of their lives.
Mother’s side of the family (maternal grandparents and great-grandparents)*
Share what you know about your mother’s side of the family, including your maternal grandparents and great-grandparents (or as many generations you have information on). Include any details about miscarriages, abortions, illnesses, causes of death, dates of birth and death, and notable characteristics of their lives.
Father's side of the family (paternal grandparents and great-grandparents)*
Share what you know about your fathers’s side of the family, including your paternal grandparents and great-grandparents (or as many generations you have information on). Include any details about miscarriages, abortions, illnesses, causes of death, dates of birth and death, and notable characteristics of their lives.

Releases and Policies
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Emergency Contact

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Emergency Contact - Phone Number
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New Client Intake Form

Personal Details

Personal Details: Family and Marriage

Your Life Timeline

Uncovering Life’s Challenges: Your Emotional Journey

Before You Were Born: Your Parents’ Journey

Describe your family tree

Releases and Policies