New Client Intake Form for Nicole Armit

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Name
First Name
Last Name
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Email
example@example.com
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Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Your Date of BirthAfter your birth date is chosen on the calendar, please ensure to TICK the pop up box below before clicking on NEXT.
Date
Year
Month
Day
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If known, please add your time of birth, and City/Town of birth, and Country (if overseas).
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How did you hear about me?Eg Referred by a friend/health professional; social media; media article; podcast interview etc
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What is your occupation/s or how do you spend a majority of your time?
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Phone NumberMobile Phone Number Preferred. Please note a reminder sms for your appointment will be sent to your mobile.
Area Code
Phone Number
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Please provide an emergency contact name and phone number
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Please provide the name of your primary healthcare provider and qualification, eg Dr Boyd - GP or Jane Law - Naturopath
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What issue/s are you coming for in this initial session?
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Do you have any children? If so, please state how many, and if they are over/under 18 years of age.
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If you are female, and are wanting to have a child/more children-please share what your story has been so far. Please include any terminations or miscarriages if relevant.
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If you are female, and are experiencing / have experienced issues relating to your reproductive health, or have history of any sexual trauma/abuse, please share what your story has been so far.
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There are many reasons why people may seek professional assistance for various health issues. Please tick any of the below that may relate to you.
Depression
Anxiety
Stress
Weight Loss/Gain
Lack of Motivation
Insomnia
Trauma Past/Current
Relationship Issues
Unwanted Habits
Drug Dependency /Addiction
General Fears
Goal Setting
Phobic Reactions
Emotional Instability
Grief/Sadness
Nightmares
Chronic Pain
Chronic Illness
Anger Issues
Other issues not stated
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What daily activities are you finding are affected or limited by these issues? Please elaborate what is affecting you.
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Are you taking any medical or recreational drugs? If so please state below.
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Have you been to hospital for any reason?
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How much time do you have to relax, and what do you do to relax?Eg Hobbies, meditation, reading etc
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What kind of exercise do you do? How frequently do you exercise?
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Please tick any of the below feelings you may have felt in the past 12 months.
Criticised
Abused
Overworked
Paralysed
Fearful
Uncertainty
Worried
Intolerant
Paranoid
Depressed
Persecuted
Grieving
Impatient
Aggravated
Overwhelmed
Nervous
Unable to Grieve
Rejected
Guilty
Apprehensive
Overwhelmed
Exhausted
Intimidated
Annoyed
Muddled
Panic
Despair
Easily Irritated
Agitated
Restless
Angry
Sad
Rage
Hopeless
Helpless
Anxious
Uneasy
Irritable
Outraged
Distressed
Suicidal Feelings or Thoughts
Loneliness/ Isolation
Other feelings
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Please rate your level of work stress out of 10.1 being NO STRESS, 10 being EXTREMELY STRESSED.
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Please rate your level of family stress out of 101 being NO STRESS, 10 being EXTREMELY STRESSED.
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Please rate your level of financial stress out of 101 being NO STRESS, 10 being EXTREMELY STRESSED.
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Please rate your level of relationship stress out of 101 being NO STRESS, 10 being EXTREMELY STRESSED.
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Please rate your level of health stress out of 10 (Mental &/Physical)1 being NO STRESS, 10 being EXTREMELY STRESSED.
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Please rate your level of other stress out of 101 being NO STRESS, 10 being EXTREMELY STRESSED.
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Please tick the following in agreement before signing...
I authorise this therapist to perform the session for my child (if signing for a minor under 18 years old) Please note a supervising adult must be present while the child is in the therapeutic space online/in person
I understand that this is an alternative treatment and if there are any medical concerns, I need to talk to my GP or medical professional. Please know that if you disclose that you are suicidal in the session, it is my duty of care to contact your emergency contact, and health care provider to ensure you have the adequate support you need.
I acknowledge that this therapy has no sexual intent, and touching the therapist is strictly prohibited, or in an online session the conversation will remain strictly professional. The session will end immediately if this is breeched.
I release this therapist for any responsibility in case of an accident, illness, or injury.
I acknowledge that if any of my circumstances change in regards to my health, I will disclose this so that the practitioner is away and can if needed modify the session to assist me better.
I acknowledge that all information I provided in this form is true and accurate
I understand my information is kept private and secure according to The Information Privacy Act 2009 (Qld-Australia) (IP Act) and will not be onsold or shared to any other parties without my written consent
I acknowledge that if the practitioner chooses to end the client journey with me, I will be referred to an alternative support provider as per professional duty of care requirements.
I acknowledge 48 hours notice is required of cancellation, unless an emergency situation.
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Do you have any issues or information important to your wellbeing or reason for attending sessions with me prior to the session that I should be aware of? This may be where you timeline any major traumas you have experienced in your life that may be impacting you on some level of your being, calling for your attention.
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SignaturePlease sign or type your name below to confirm all the information above is true and correct to the best of your knowledge. Also confirming with your signature that you are over 18 years of age.
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