Client Intake Form

Name*

First NameLast Name

Date of Birth*

Date

Email*

example@example.com

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Emergency Contact Person*

First NameLast Name

Emergency Contact Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

How did you hear about us?

Do you have any medical conditions or concerns?*

Are you currently taking any medications? If yes, please list them below.*

Do you have any allergies? If yes, please list them below.*

Do you have any of the following?

Rows	Yes	Details of Condition
High Blood Pressure (Hypertension)
Arrhythmias or Irregular Heart Beats
History of Heart Attack (MI)
Asthma
History of Anxiety
Night Sweats
Skin Disorders
History of Depression
History of PTSD
Difficult sleeping
ADHD
History of Complex Trauma
Chronic Pain Condition
Migraines
Panic Attacks
Trouble coping with everyday life
Helplessness or Hopelessness
Heightened Stress
Digestive Issues

Please explain any personal issues you are experiencing or having difficulty coping with.*

When did the problem or issue begin?*

What do you think the root cause of the problem or issue is?*

Please explain what you wish to gain from our session?*

What other therapies have you tried?*

Disclaimer and Confidentiality Agreement
For Holistic Counselling, Life Coaching, or Soul Sessions

Holistic Counselling, Life Coaching, and Soul Sessions are confidential and collaborative processes designed to support your personal growth, emotional wellbeing, and self-awareness. These services aim to help you explore concerns, discover insights, and develop strategies for positive change.

These sessions may involve the sharing of sensitive, personal information, and at times this may feel emotionally challenging.

You will be supported in a safe, non-judgmental space by Julie-Anne who is committed to helping you reach your individual goals.

Our sessions are 90 minutes.

Each session may include a blend of Holistic Counselling, Life Coaching, Meditation, and Creative Arts Therapies.

Julie-Anne draws upon a range of supportive modalities to meet you exactly where you are, ensuring each session is tailored to your unique needs and intentions.All information shared during your session will remain private and confidential, in accordance with ethical guidelines and legal requirements.

While the process is often transformative and supportive, the outcome of these sessions will vary for each individual and cannot be guaranteed. However, please know that you will be supported throughout your journey with compassion and integrity.

By participating in these services, you acknowledge that you have read and understood the terms above, and you agree to the confidentiality guidelines and cancellation policy as outlined.

Exceptions to Confidentiality:
Confidentiality will be maintained unless one of the following exceptions arises:

There is clear or imminent risk of harm to yourself or others.

There is a legal obligation to report certain information, including disclosures related to abuse or risk of serious harm.

A valid court order is issued, requiring the practitioner to release records or provide testimony.

Cancellation and Payment Policy:

A 50% payment is required at the time of booking to confirm your session.

The remaining balance is due on the day of your appointment.

A minimum of 24 hours' notice is required to cancel or reschedule any appointment.

Cancellations made with less than 24 hours' notice will incur a $75 late cancellation fee.

Prompt arrival is appreciated. Please notify us if you are running late.

I understand that a 24-hour cancellation notice is required for all scheduled appointments. I understand that my appointment will be rescheduled, not refunded.I understand a late cancellation fee of $75.00 will be charged for failing to give 24 hours' notice.I certify that all information in this form is accurate and true to the best of my knowledge. I have not intentionally withheld any viable information that may be useful or relevant for my session.I understand that the full fee is $150.00 for a 90-minute session, and the balance is required on the day of the appointment.I have read the above information. I understand the potential benefits and risks of engaging in Holistic Counselling, Life Coaching, or Soul Sessions, as well as the nature and limits of confidentiality. I am aware of what is expected of me as a client of The Soul-Full Mind. I acknowledge that Julie-Anne and The Soul-Full Mind do not provide medical advice, nor do they claim to be medical doctors. Any guidance, suggestions, or information offered during sessions is intended to support personal well-being and is not a substitute for medical, psychological, or psychiatric treatment. I take full responsibility for my participation and well-being throughout the process.

Your Signature*

Date Signed*

Date

Client Information

Medical Conditions

Client Acknowledgment