Intake Questionnaire

Initials

Date of Birth

Date

Gender

Pronouns

Relationship Status

Who do you live with?

Do you have children, if yes, how many?

Do you have pets, if yes, how many?

What is your current employment?

What is your sexual orientation?

Why are you seeking help?

Have you received therapy in the past? Please share anything important about your experience or whatever you want me to know in order to help you.

Current Symptoms

List all current prescription medications and how often you take them

Current physical medical problems?

Current mental health struggles? Have you been diagnosed?

What are the mental and physical health struggles in your family?

Please share basic information about your childhood, including siblings and the ages, and anything important about your parents.

Is there any information you want to share about your childhood/family?

Do you have a history of being abused emotionally, sexually, physically or by neglect? If yes, please describe when, where and by whom.

In the past five years, has there been any traumatic experiences in your life?

What are you hoping to achieve in this process? What are your goals?

Have you ever had feelings or thoughts that you didn't want to live?

On a scale of 1 to 10, (ten being strongest) how often do you feel unhappy?

Do you or have you ever self harmed?

How often do you exercise?

Average hours of sleep per night?

How often do you drink?

Do you smoke cigarettes?

What is your coping mechanism?

Do you use any substances, if yes,which ones and how often?

EMDR Acknowledgement and Consent Form

Eye Movement Desensitization and Reprocessing (EMDR) methodology is a form of adaptive information processing that may help the brain unlock maladaptive material. I have been advised that EMDR is a treatment approach that has been widely validated by research on Post Traumatic Stress Disorder (PTSD). Research is occurring on other ways EMDR can be applied.

I have been specifically advised of the following:
a) Distressing, unresolved memories may surface through the use of the EMDR procedure.

b) Some clients have experienced reactions during the treatment sessions that neither they nor the administering clinician had anticipated, including but not limited to high levels of emotional or physical sensations, disorientation, fear, and nausea.

c) After the treatment session, the processing of incidents and/or material may continue, and dreams, memories, flashbacks, feelings, etc., may surface.

d) Those with limiting or special medical conditions (pregnancy, heart condition, ocular difficulties, etc.) should consult their medical professionals before participating in this therapeutic method. Pregnant women should postpone reprocessing.

e) If you are involved in a legal case, be sure to discuss this with your therapist.
Before beginning EMDR treatment, I have considered all of the above, and I have obtained whatever additional input and or professional advice I deemed necessary or appropriate.

By my signature below, I hereby consent to receiving EMDR treatment. My signature on this Acknowledgment and Consent are free from pressure or influence from any person or entity. I understand I may stop treatment at any time before or during any EMDR session and that more than one EMDR session is usually necessary in the treatment.

In addition, by signing below, I confirm I am the person in the "initals" section and that all the information entered above is true to my knowledge.

Signature

Today's Date

Date