Client Intake Form

CLIENT INTAKE FORM
Name:

First NameLast Name
Old Name (Hidden)
Age:
Birthdate:
Email
example@example.com
Phone:
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation:
Today's Date:
Emergency Contact: Name

First NameLast Name
Emergency Contact: Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact: Email
example@example.com
Referred by:
Please complete this questionnaire thoroughly so we can help you have a safe and beneficial experience. It is very important that we are aware of your medical conditions, medications, supplements, life experiences and habits that may influence you. This is a confidential record.
PURPOSE
What are your reasons for seeking to do this work?
What are your goals, hopes, expectations?
What are your concerns or fears?
JOURNEY EXPERIENCE HISTORY
Are you experienced with medicine journeys? If so, what types of journeys have you experienced? Has it been in a recreational or ceremonial context? Please describe in detail the type of substance taken, when, how much (if known), and the situation or purpose of taking the substance.
What influence have these journeys had on your life?
Have you had any challenging or problematic experiences? If yes, please describe in detail what you took and what happened.
Page 1

For the following questions, you only need to answer YES or NO. We can discuss further in our initial sessions.
Have you ever had a psychotic episode?
If YES to the previous question, please share as much detail as you can.
Have you ever been abused? (It can be sexual, mental, physical or emotional or all of these.)
If YES to the previous question, please share as much detail as you can.
Have you experienced trauma (For example: Motor vehicle accidents, rape, mugging, robbery, being a witness to violence, Etc.?)
If YES to the previous question, please share as much detail as you can.
Do you experience fear or paranoia?
If YES to the previous question, please share as much detail as you can.
Have you ever been suicidal?
SUBSTANCE USE HISTORY
Please describe your use of any substances throughout your life and especially during the past three months.
Have you had any adverse reactions to alcohol, drugs, or any consciousness-altering substances? Please describe in detail the type of substance taken, when, how much (if known), the situation or purpose of taking the substance, and the adverse reaction.
Do you have any history of substance abuse? Have you ever been treated for substance abuse? If so, please describe. Include addictive behaviors such as sex, co-dependency, gambling, internet, porn.
Page 3

Have you ever been diagnosed with an eating disorder such as bulimia or anorexia or "disordered" eating. Please describe.

How much tobacco, alcohol, coffee, tea and soda do you consume?

Rows	Quantity
Tobacco (#cigs p/day)
Alcohol (# drinks p/week)
Coffee/Tea (# cups p/day)
Soda (#oz p/day)

DETAILED MEDICAL HISTORY
How would you describe your overall health?
What is your current body weight?
Do you currently have any medical conditions? If so, are you currently in the care of a health care professional? Please describe the conditions and current treatment.
Do you have a history or present condition of high or low blood pressure? If so, please explain.
Could you be pregnant?
Page 4

When was your last complete physical exam (month/year)?
Anti-anxiety meds. If so, what kind?
Anti depressant meds. If so, what kind?

What medications are you currently taking? (It is essential that you list ALL Rx meds.)

Rows	Medication	Dosage	For What?	Since when?
1
2
3
4
5
6
7
8
9
10

Please list any supplements that you are currently taking:
Are you more or less sensitive to medications than most people? (i.e. Have you had to take more or less of a medication's recommended dose to experience the desired effects?) If so, please describe:
Have you had any adverse reactions to medications or supplements? Do you experience side effects from medications or supplements? If so, please describe:

Have you taken B vitamins or gaba regularly or irregularly in the past or present?

Do you take (or have you taken) any of the following supplements regularly?

Rows	Current	Past
Guarana
St. John's Wart
Licorice
GABA

FAMILY Current Family (who you live with, see regularly):
With whom do you live?
What is your current relationship status?:
If you are currently in a romantic relationship(s), how long?
On a scale of 1-10, how would you rate your satisfaction with your current relationship(s)? (1-low, 10-high)
Please describe briefly your reason for choosing the rating you choose.
If you are currently in a relationship, do you sleep in the same bed as your partner?
Who are the most important people in your life?
Do you have pets? If yes, please describe.
How supported by your family do you feel?
Are you living with conflict?
How much can you share about your personal process with your family and friends?
Do you feel comfortable asking your family for help if needed? Who is looking out for you?
Children, if any. (names and ages):
Are your parents living? If no, what age were you when they passed?
If yes, do you currently have a relationship with them? Mom?
Page 7
Dad?
Are they separated?
If so, what age were you when they separated?
What was the custody arrangement?
What sisters and brothers did you have at the time of birth, and what siblings came later?
In your childhood did you experience severe illness, trauma, accidents or other childhood challenges? Please describe in detail.
How much water do you drink daily?
Do you eat grapefruit or grapefruit juice regularly?
SLEEP
How many hours do you sleep per night?
Do you wake refreshed?
Do you have difficulty falling asleep?
Difficulty staying asleep?
Is there anything else you you would like to add that might impact your success as we move forward?
Signature
Should be Empty:

Rows	0	1	2	3
Anxiety
Depression
Bad Temper
Hopeless Outlook
Lonely
Easily Stressed
Poor Memory
Angry Outbursts
Nervousness

CLIENT INTAKE FORM

PURPOSE

JOURNEY EXPERIENCE HISTORY

MENTAL HEALTH HISTORY

SUBSTANCE USE HISTORY

DETAILED MEDICAL HISTORY

FAMILY Current Family (who you live with, see regularly):

SLEEP