One to One Online Art Therapy Sessions

One to One Online Art Therapy Sessions – Adult

Thank you so much for your interest in working with me one to one in online art therapy sessions. I look forward to journeying with you. This form gives me information about who you are, what you would like to work on in our sessions. Please carefully complete this form before our first session together. I will go over some parts of this form with you during our first session and will send you a consent form to sign. If you have any questions about this form or the consent form please reach out to Katlyn (blueflamearttherapy@gmail.com).
Personal Information
Full Name*

First NameLast Name
Preferred Name (if different)
Sex & Gender*

Sex (as assigned at birth)Gender (current gender, which may be different than what is indicated on your insurance policies or medical record)
Pronouns
Contact Information*

Phone NumberEmail
Birthdate*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Occupation
Emergency Contact Name*
First and Last Name
Emergency Contact Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Relationship*
Family Doctor Name
Family Doctor Phone (if known)
Please enter a valid phone number.Format: (000) 000-0000.
Family Doctor Email (if known)
example@example.com
Referring Professional Name
Referring Professional Phone (if known)
Please enter a valid phone number.Format: (000) 000-0000.
Referring Professional Email (if known)
example@example.com

Intake Questionnaire

Please review the questions below, and answer them to the best of your ability at this time. This helps me understand how I can best support you.
What has led you to seek art therapy at this time?*
How long have you been having these difficulties?*
How do these difficulties affect your life? (Please answer for each area that applies and write N/A for any that don't apply)
Work*
School*
Finances*
Health/Wellbeing*
Relationships*
Other (not listed above)
How have you been coping with these difficulties until now?*
Have you received art therapy or therapy in the past? If yes, what did you find helpful?*
What would you like to gain from art therapy at this time?*
Alcohol/substance useSignificant life changes or stressful eventsSignificant losses or traumasAny personal or family history of suicidal ideation, risk, or attempt (please specify when below)I have experienced none of these above
For the areas you have checked above please share more about when these experiences happened, how long it lasted, and other details you would be willing to share or write N/A if it doesn't apply.*
Do you have any spiritual beliefs/practices that are important to you?
What are your strengths? Who or what resources you? (people/animals/activities)*
Please add anything else that you would like me to be aware of to support your art therapy experience

One to One Online Art Therapy Sessions – Adult