POWERS BENZO COACHING

POWERS BENZO COACHING

New Client Intake Form. HIPPA Compliant & Protected.
Full Name

First NameLast Name
Age?
Contact Email
example@example.com
Contact Number

Area CodePhone Number
Country of Residence?
What country do you live in?
State of Residence?
What State do you live in?
Are you currently tapering, post-withdrawal, or still taking benzodiazepines?

Currently taperingFully off (post-withdrawal)Still taking benzodiazepinesOther
What benzodiazepine are you currently taking?
Usual dose of benzo?
Current dose of benzo?
How long have you been on benzos?
If tapering, how long have you been tapering?
If already tapered, how long have you been off of benzodiazepines?
What other medication(s) were/are you on, and for how long?
(Include dosage history if possible)
Have you taken any other psychiatric medications (SSRIs, SNRIs, etc.)?
(Include dosage history if possible)
Have you ever been formally diagnosed with any mental health conditions?

Generalized Anxiety Disorder (GAD)Panic DisorderOCDDepressionPTSDHealth Anxiety / HypochondriaInsomniaOther
Have you ever been diagnosed with or suspect you have any neurological or autoimmune conditions?
(E.g., POTS, Dysautonomia, Lyme disease, Fibromyalgia, etc.)
What are your TOP THREE most difficult symptoms right now?
(E.g., anxiety, depression, intrusive thoughts, insomnia, fatigue, derealization, etc.)
How physically active are you?
How often do you get out of the house?
Can you operate a vehicle?

Yes, easilyYes, but with difficultyNo
Do you have a therapist?

YesNoSeeking
Do you struggle with obsessive rumination?

YesNoUnsure
How is your sleep currently?

NormalizingPoor but manageableSevere Insomnia
How would you describe your energy levels?

NormalSome fatigueSevere fatigue (struggle with daily tasks)
Do you experience any of the following neurological symptoms?

TinnitusBurning skin / nerve painInternal vibrations / tremorsAkathesiaCognitive issues (brain fog, memory problems, difficulty focusing)Sensory hypersensitivity (light/sound sensitivity)
How do you currently cope with withdrawal symptoms?

Mindfulness or meditationExercise / movementDistraction techniques (work, hobbies, etc.)Seeking reassurance (forums, Youtube, constant symptom-checking)Avoidance (isolating, avoiding activities due to fear)Other (please list)
Do you feel your relationship with fear is one of your biggest obstacles?

YesNoUnsure
Do you engage in avoidance behaviors (avoiding places, activities, sensations, etc.) due to fear?

FrequentlySometimesRarelyNever
How often do you check withdrawal forums or seek reassurance?

DailyMultiple times per weekOccasionallyRarely or never
What are your top 3 goals for coaching?
(E.g., managing anxiety, improving sleep, breaking avoidance, calming limbic system, etc.)
Are you looking for:

A structured, step-by-step program (North Star)Personalized 1-on-1 guidance & deeper coachingA mix of both

How committed are you to actively working on your recovery?

	1	2	3	4	5

1 is Not ready, 5 is Fully committed & willing to challenge myself

Do you have any major concerns or expectations for coaching?
(Please list anything you feel is important for me to know.)
Is there anything you feel is holding you back from recovery?
(E.g., fear, lack of motivation, financial stress, etc.)
How did you hear about this coaching program?
(Youtube, referral, website, forum, etc.)
I understand that Coach Powers offers Coaching and NOT Therapy.
I understand that I should ALWAYS inform my doctor(s) of the work I do in benzo coaching and that their medical orders are paramount.
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