New Client Intake Form

New Client Intake Form!

Hi, I'm so glad you're here! Please fill this out before our first session together. This helps me get a quick snapshot into your life and helps me prepare for our meeting. All answers will be held with care.
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Age/DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
What time zone are you in?
Did anyone refer you to me?
Relationship?

Other
Children?

Other
Have you had sessions in any of the following:

Other
If you have, how long did you try it? Was it overall a helpful or positive experience or not, and why?
Please briefly (with a few sentences) describe 2 or 3 difficult experiences that have significantly impacted you in some way. For each experience, please also list a few things that might have felt like a resource to you (brought you joy, peace, or hope) during that time.
What are you hoping to work through in this season? What led you to seek out help?
Do you anyone else with whom you can process these things or be supported by in this season?
In general, how relationally supported do you feel in this season? Do you have stable community or social supports? What does "relational support" look like for you in this season?
What are your hopes or expectations in pursuing Life Consulting with me?
Are you familiar with the "4-F" responses and how they present in your body? (Fight, flight, freeze, and fawn)? If "yes", which do you notice most often as a common response?
Are you familiar with Attachment Styles (avoidant, anxious, disorganized, secure), and how they might show up in your life? If so, what do you think you tend towards?
Are you familiar with the concept of "triggers" or trauma flashbacks, and how they might show up in your life?
Have you ever done any personality tests? (Enneagram, Myers-Briggs, etc.) If so, care to share what type you resonate with?
Please check any of the following that you are currently experiencing, or experience fairly often in your life.

Other
If you selected "other," please elaborate. Feel free to elaborate on any of your other selections as well!
Have you ever been under the care of a mental health professional (e.g., a psychologist, psychiatrist, inpatient care, or outpatient team)? If so, please describe the treatment you received and why.
Are you currently on any medication to help with a mental health difficulty? Please describe how you feel this medication affects you, if at all. (*If you are taking medication while we meet together, please let me know if you plan to stop taking it during the course of our meetings together.)
Have you ever engaged in any self-harm behaviors (i.e., cutting, burning, biting, hitting, starvation, binging, or purging)? If yes, how long did you engage in these behaviors and how frequent were they?
Have you ever experienced thoughts of wanting to end your life? Or, are you currently experiencing any thoughts of wanting to end your life? If so, how recently? How frequently did you/do you experience these thoughts?
Have you ever attempted to take your own life? If so, how recently? Was this an impulsive decision or something that was thought out?
Have you experienced chronic pain or chronic illness in your past or present? Please describe.
Do you have any medical conditions that might impact your ability to have sessions with me?
Is there anything else that would be helpful for me to know about you or help explain your current season?
Are you interested in receiving little "homework assignments" (things to try out, read, journal about, etc.) as a way to engage growth/healing outside of our times together?
Emergency contact information (someone who lives near you) - please include their name, relationship to you, their phone number, and email address:
Thank you for taking the time to fill this out! I look forward to meeting with you. :-)
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New Client Intake Form!