Pure And Free | New Client Intake Form

New Client Intake Form
Name*

First NameLast Name
Email*
Phone Number*
Birthdate*

MonthDayYear
How did you hear about Pure And Free?*

ChurchCounselorOnlineSocial MediaFriend
Lifestyle Questions
Marital Status*

SingleMarriedDivorcedSeparated
Do you have kids?*

YesNo
Do you have any hobbies?*

YesNo
What do you do for work?*
How many hours per week do you work?*

20-3030-4040-5050+
Does your work fulfill you?*

YesNoSometimes
How well do you sleep at night?*

Great, no issuesGood, a little restlessOkay, could be betterBad, what's sleep?
How many hours per night do you sleep on average?*

3-44-55-67-8+
Do you struggle to fall alseep?*

YesNoSometimes
Spiritual, Mental, and Emotional Health
What is your religion?*
How active are you in your faith?*

Very, I feel connectedPretty Good, I check the boxesOkay, It's a family thingNot active, It's not my thing
In your opinion, what role does God play in helping you get through your current sexual struggles?*
Do you struggle with intrusive thoughts?*

Yes, all the timeNo, not a problem for meSometimes, it happens
Do you struggle with focusing your mind on one thing at a time?*

Yes, all the timeNo, not a problem for meSometimes, it happens
Have you ever been diagnosed, or thought you should be diagnosed with, any of the following:*

ADHDMultiple Personality DisorderAutismDepressionObsessive Compulsive DisorderAnxietyNone
In your opinion, how well do you identify, feel, and communicate your emotions?*

AmazingOkayNot wellWhat even are emotions?
List your 3 top stressors in life*
1.
2.
3.
Sexual Integrity
Why are you interested in private coaching?*

Compulsive masturbationMarital affair(s)PornographyHarmful, unsafe, or unwanted sexual behaviorLust and fantasy
Do your sexual struggles involve other people or money?*

YesNo
How much time are you willing to commit towards change each week?*

0-1 hours1-2 hours2-3 hours4-5 hours
If married, how aware is your spouse:*

They know nothingThey know someThey know mostThey know absolutely everything
Commitment To Change
Readiness to change:*
What are you willing to do to achieve this change?*

Lifestyle changeJoin a support groupRead and listen to recovery materialsAdd recovery practices to my lifeRemove unhealthy practices from my life
What are your long-term goals regarding your sexual struggles?*

100% sobrietyDecrease fantasy and lust in the mindRestore my relationships (marriage, family, etc.)Just minimize/control toxic sexual behaviorRestore my sexual health
What issues do you foresee getting in the way of you accomplishing these goals?*

Lack of commitmentNot enough time or energyAshamed or shy about the topic of sexDenialDishonestyUnable to maintain sobriety
Payment Authorization

Please complete all fields. You may cancel this authorization at any time by contacting us. This authorization will remain in effect until canceled.
Payment Policy

Clients are asked to save a card on file. All payment information is saved and securely encrypted with Square. Your card will be charged on the day of or day after your appointment.
Card Type*

MastercardVisaAmerican ExpressOther
* Please Note: You will not be charged by submitting this information.
I, First Name Last Name , authorize Pure And Free Recovery to charge my card above for agreed-upon purchases. I understand that my information will be saved to file for future transactions.
Please sign here to confirm that you have read and agreed with the Payment Authorization Policy.*

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Today's Date*

MonthDayYear
Scheduling and Privacy
Late Appointments & Cancellation Policy

If you are late for your appointment, we will only have the allotted time left from your scheduled appointment time. We will need to honor our other client's previously scheduled appointment times.

If you need to cancel an appointment, please give a 24-hour notice in order to avoid being charged a session fee. We have reserved that time slot for you, and you will benefit most if you are on time for your appointments and respectful about cancellations.

If you have a true emergency that is not anticipated, then the 24-hour notice policy may be waived per basis. Thank you for your understanding.

Client Confidentiality

Private and privileged information will be shared during the coaching sessions. All information, whether spoken or communicated in writing, will be kept strictly confidential unless prior, written approval is granted by the Client. We take the confidentiality and anonymity of our clients very serious. We are honored to walk these "sacred paths" with you.
Please sign here to confirm that you have read and agreed with the Scheduling and Privacy Policy.*

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New Client Intake Form

Lifestyle Questions

Spiritual, Mental, and Emotional Health

Sexual Integrity

Commitment To Change

Payment Authorization

Scheduling and Privacy