Individual Intake Form

Individual Intake Form

Complete this intake form using the extracted fields from the source PDF. Please answer all applicable questions as accurately and comfortably as you can.
Demographics
Date

MonthDayYear
Date
Name
Date of Birth

MonthDayYear
Date
Place of Birth
Name preference during session
Where did you grow up?
Current Residence
Position of Birth
Number of Siblings
Number of Brothers
Number of Sisters
What did you hear your parents say about you during pregnancy?
Preferred gender pronouns
Relationship status

Other
Current relationship rating
Are there concerns you'd like to address in session about relationship?
Relationship concerns – brief sentence
Do you have children?
If yes, number and ages of children
Family History
Growing up (0–13 years) experience rating
Childhood unsafe experiences
If yes, please share
Adolescence (13–21 years) experience rating
Adolescence unsafe or difficult events
If yes, please share
Family of origin type

Other
Parent status
Relationship with Mum – rating
Relationship with Mum – description
Relationship with Dad – rating
Relationship with Dad – description
Relationship with Siblings – rating
Relationship with Siblings – description
Parental/sibling behaviors that have shaped who you are
Trauma & Body History
Trauma & body history: experienced events

Other
If you checked any above, please share what feels comfortable
Do you experience chronic pain or tension?
If yes, where in your body? How long have you had it?
Do you have any recurring physical symptoms that doctors can't fully explain?
If yes, please describe
When stressed or overwhelmed, I tend to
How do you know when you're becoming dysregulated?
What helps you come back to feeling calm or centered?
How connected do you feel to your body on a typical day?
Comfort noticing sensations in your body
Parts of your body you avoid feeling or paying attention to
Sensory sensitivities

Other
Sensory sensitivities – Other
Soothing or triggering smells, sounds, textures, or sensations
How is your breathing typically?
How do you generally feel about being touched (professionally)?
Have you ever experienced unwanted touch or violations of your physical boundaries?
Openness to optional, consensual, light touch
Anything else about touch or boundaries I should know
Previous body-based experiences

Other
Previous body-based experiences – Other
Experience of previous body-based practices
Lifestyle & Health
Sleep – hours per night
Sleep – what helps?
What makes sleep difficult?
Eating – description of eating habits
Challenges with appetite or body image
Do you move regularly?
Types of movement or exercise
Frequency of movement or exercise
When I feel stressed, I usually
I feel most grounded when I
Current physical health
Current mental health
Concerns about current/past medical & health history
Have you had therapy before?
If yes, what was helpful or unhelpful about therapy?
Current medications
Physical limitations affecting movement or exercise
Precautions for somatic practices

Other
Precautions – Other
Risk & Safety
Have you ever had thoughts of hurting yourself?
Have you attempted suicide before?
If yes, when?
If yes, how?
Are you currently feeling suicidal?
Additional information about suicidal thoughts or feelings
Have you lost anyone to suicide?
Relationship to person lost to suicide
When did this loss occur?
Should be Empty:

Individual Intake Form

Demographics

Family History

Trauma & Body History

Lifestyle & Health

Risk & Safety