Unmask Your Strength: A Survivor’s Path to Thriving Intake Form

Basic Information
Client's Name*

First NameLast Name
Client's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Client's Phone Number*
Format: (000) 000-0000.
Client's Email Address*
example@example.com
Marital Status*

SingleMarriedDivorcedWidowed
Date of Birth

MonthDayYear
Date
Occupation*
About your experience
When did the assault(s) occur?
If you have discussed it with someone, briefly describe how that was received:
Where are you currently in your personal healing journey?

Never talked about itDiscussed with at least one or more persons
What other significant events were happening before the assault(s), or have happened since the assault(s) that have made life more stressful?
Are you currently receiving care from a psychiatrist, psychologist, counselor, or other mental health professional?

YesNo
Any previous counseling or therapeutic help (if so when and the nature of the problem):
Are there any other things currently going on that you feel may hinder or help you through this process?
Interest in the Program
What drew you to this program?
What are you hoping to gain from participating?
Where do you currently feel you are in your healing journey?

Goals
What areas of healing or growth would you most like to explore during this program?
Describe how your life will be different once you've completed this program?

Current Support System
Do you currently have emotional support available to you (friends, family, therapist, counselor, etc.)?

YesSome supportLimited support
Who do you consider to be in your support system? (Names and relationship to you)
How would you describe your ability to carry out daily living activities?
The Foundational Course includes weekly live group sessions with other participants. These sessions focus on reflection and learning rather than detailed trauma recounting.
Are you comfortable participating in a structured group environment?*

YesMaybe/I have questions

Thank you for taking the time to complete this intake.

All submissions are reviewed personally before enrollment is confirmed.

If the program appears to be a good fit, you will receive an email with next steps and enrollment details.
Before submitting this form, please confirm the following:*

I understand this program is educational and coaching-based and is not therapy or clinical mental health treatment.I understand participation may involve emotional reflection and personal responsibility for self-regulation.I have reviewed the Program Policies, Terms & Conditions, and Privacy Policy provided on the Adrienne Sharee Enterprise website.I understand enrollment is not guaranteed and applications are reviewed to ensure the program is an appropriate fit.I understand payment details will be provided if my application is approved.I understand that live group sessions require confidentiality and that participants are expected to respect the privacy of others.
Program Policies | Terms & Conditions | Privacy Policy
Signature
Date Signed

MonthDayYear
Date
Should be Empty:

Rows	0- Never	1-Occaionally	2-Sometimes	3- Very Often
1. Unwanted thoughts or images about the trauma
2. Bad dreams or nightmares about the trauma
3. Feeling as though the event is happening again (flashbacks)
4. Extreme distress when encountering reminders of the trauma
5. Extreme bodily reactions when reminded of the trauma (i.e. heart races, tense)

Rows	0- Never	1-Occaionally	2-Sometimes	3- Very Often
1. Unwanted thoughts or images about the trauma
2. Bad dreams or nightmares about the trauma
3. Feeling as though the event is happening again (flashbacks)
4. Extreme distress when encountering reminders of the trauma
5. Extreme bodily reactions when reminded of the trauma (i.e. heart races, tense)

Rows	0- Never	1-Occaionally	2-Sometimes	3- Very Often
6. Avoidance of thoughts or feelings associated with the trauma, including avoidance of talking about it
7. Avoidance of situations or people that remind you of the trauma (i.e. affection or sexual relations)
8. Having difficulty remembering important parts of what happened

Rows	0- Never	1-Occaionally	2-Sometimes	3- Very Often
9. Feeling less interested in activities that were important to you
10. Feeling cut off from others or distant and unable to connect
11. Feeling emotionally numb especially when it comes to positive feelings like love or joy
12. Feeling like your life will be cut short or that you won’t live as long as you once expected

Rows	0- Never	1-Occaionally	2-Sometimes	3- Very Often
13. Continual problems falling or staying asleep
14. Extreme irritability or outburst of anger
15. Continual difficulties concentrating
16. Constantly feeling on guard or watchful (hypervigilance)
17. Feeling extremely jumpy and easily startled
18. Loss of appetite or weight gain

Basic Information