Getting To Know You

This is NOT an on-boarding call. >> All Information collected on this form is kept confidential and is shared with no one except for Tah Whitty and Kole Whitty.

Your honesty and vulnerability is greatly appreciated. It helps us know where you are, where you want to go and how you got here. We honor your privacy and the safety of your information. This record is encrypted and password protected and will NOT be duplicated or printed.
Name *

First Name Last Name
What name do you prefer for us to call you? (We want you to be called what is most comfortable for you. Nicknames are perfectly acceptable.) *
Name we should call you
How Much Have You Typically Invested In Coaching/Transformational Work (including therapy, body work etc) *

I haven't ever spent money on anything like that Less Than $1k Per Year Between $1k-5k Per Year Between $5k-10k Per Year More than 15K Per Year
What interests you as far as working with TahKole? *

1 on 1 Coaching with Kole 1 on 1 Coaching with Tah Group Coaching Weekend Intensive Condor Mastermind Community Group One Day Workshop Couple's Retreat 2 on 2 Couples Coaching Intimately Tied "Sensory Modulation" Retreats
What made you reach out? *
Phone Number *

Area Code Phone Number
Email *
example@example.com
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Age *
Date of Birth *

Month Day Year
Date
Biological Sex *

Female Male Prefer not to say
Gender Identity *

Cisgender / Heterosexual Woman Cisgender / Heterosexual Man Homosexual Woman Homosexual Man Transwoman Transman Trans* Gender Fluid Prefer not to say
What country were you born in? *
What Race do you consider yourself? *
What Ethnicity do you consider yourself? *
What Languages do you speak? *
Relationship Status (Choose as many as apply) *

Single Engaged Married Separated Divorced Divorced and Remarried Widowed In a Monogamous Relationship In Polyamorous Relationships Open Relationship
How did you hear about us? Did anyone refer you? *
Do you have a Religious / Spiritual Practice? What is it? *
Allergies or sensitivities to foods, medicines, animals, latex/rubber, plants *
Height *
Weight *
Occupation *
Full Medical History (Including any Emergency Room visits, hospitalizations and childhood Illnesses) *
Surgical History (Including cosmetic surgery) *
How many times a day do you normally move your bowels? *

Once Twice Three or more times I do not move my bowels every day
How would you describe your stool quality on a regular basis? *

Normal, formed Loose Watery Hard Bloody
What is your urine color like most of the time? *

Clear Pale yellow Dark Yellow Brown Bloody
How does your urine normally smell? *

I barely smell it I can smell it but it is not very strong It smells strong It smells terrible
Dental History *

Braces Extractions Cavities/Fillings Gum disease Root canal
Locations in the mouth *
Do your gums bleed? *

No Yes, when I brush my teeth Yes, when I eat Yes, at random times Yes, all the time
How would you describe your eyesight? (Check all that apply) *

Perfect Pretty good I am nearsighted I am farsighted I am nearsighted and I need glasses or contacts I am farsighted and I need glasses or contacts My eyesight is pretty bad I am legally blind I am blind I cannot see with my right eye I cannot see with my left eye
How would you describe your hearing? (check all that apply) *

My hearing is perfect I am hard of hearing I am deaf I am hearing impaired I have trouble hearing in my right ear I have trouble hearing in my left ear I use a hearing aid
Describe any psychiatric/psychological diagnoses, treatment in the past or present. (please including any individual or group therapy sessions): *
Do you currently see a therapist of any kind? If so, what kind of therapist? *
Have you ever been diagnosed as Autistic? *

Yes No
Have you ever been diagnosed with ADD or ADHD: *

ADD (Attention Deficit Disorder) ADHD (Attention Deficit Hyperactive Disorder) Neither
Have you ever had suicidal ideations or ideas of ending your own life? *

Yes No
Have you ever attempted suicide? *

Yes No
Do you take any prescribed or over-the-counter medicine? *
Do you take Probiotics?

Yes No
Have you EVER experienced any PAST? (That are no longer present) *

Headaches Neck pain Back pain Shoulder pain Hip pain Knee Pain Ankle pain Chest pain Hand pain Foot pain
Are you currently experiencing any physical body pains or aches? If yes, please describe in detail below. Please include where it is located and when the pain first started. *
Past injuries that created scars? *
Locations on the body *
Any scar-less injuries? *
Do you have any diagnosed or undiagnosed skin rashes or conditions? *

Yes No
Have you had any skin lesions, warts or moles removed? *

Yes No
If yes, Please describe
Have you been circumcised? (Penis or Clitoris) *

Yes (Voluntary) Yes (Involuntary) No
Are you currently sexually active? *

Yes No
Do you enjoy sex? (Choose all that apply) *

Yes No Sex is a big source of stress for me I do it only because I feel like I have to If I could have sex every day, I would If I could never have sex again, I wouldn't
Have you ever been diagnosed with or treated for an STI (Sexually Transmitted Infection)? *

Yes No
Do you utilize any form of prescribed contraceptive? *

Oral Contraceptive Transdermal Patch Injection N/A
Do you utilize any contraceptive device that must be placed/removed or surgically installed by a medical professional *

IUD (Intra Uterine Device) Essure N/A
Did you have "all of your vaccines" as a child *

Yes No Not Sure
Did you ever have a reaction to a vaccine? *

No Yes
Did you ever have: *

Measles/ Rubeola Mumps Chicken Pox Whooping Cough Rubella Malaria Tuberculosis Shingles Meningitis None of the Above
Have you been tested for COVID-19 (Testing is NOT a requirement for attendance to our events) *

Yes (Swab) Positive Yes (Antibodies) Positive Yes (Swab) Negative Yes (Antibodies) Negative No, I have not been tested.
How much time would you say that you spend in direct sunlight most days? *

15-30 minutes 1-2 hours 2-4 hours 4-8 hours I never spend time in direct sunlight
What Is Your Dietary Lifestyle / Nutrition? *
Any Food Restrictions? *
How would you describe your eating habits? *
Do you enjoy eating (choose all that apply) *

Yes No Eating is a big source of stress for me If I didn't have to eat I wouldn't If I could eat all day, I would Eating is a source of pleasure for me Eating is a source of shame for me
How much water do you drink daily? *

1 glass (12 ounces / 0.35 liters) 2 glasses (24 ounces / 0.7 liters) 1 quart / 1 liter 2 quarts/ 2 liters 1 gallon / 4 liters or more
Do you drink caffeine daily? *
If so, how much and at what age did you start? *
Do you have exercise / movement practices? How would you describe them? *
Do you "bio-hack"? If so, what do you utilize? *
Do you smoke cigarettes / cigars / vape? *
If so, how much daily? For how long? *
Do you drink alcohol? *

Socially Occasionally Habitually (3-5 times per week) I consider myself an alcoholic I do not drink
Have you ever been admitted to a rehab or detox facility for alcohol or substance use? *

Yes No
Please Check any of the following substances that you have experienced one or more times in your life. (We do NOT share this information with ANYONE) *

Ayahuasca Wachuma / San Pedro Magic Mushrooms / Psilocybin) LSD / "Acid" Iboga / Ibogaine MDMA / Molly / Ecstasy Sassafras / Sass / MDA Marijuana / Weed / Cannabis Peyote Ketamine Rapé Sonanga Urema DMT 5MeO DMT Kambo Bufo Kanna Morning Glory / Ololiuqui Mistletoe White Lily Speed / Amphetamines Cocaine Crack Cocaine K2 / K2000
Have you ever been exposed to crop dusting? *

Yes, Once Yes, Multiple times No
Have you ever had prolonged exposure to lead or did you eat lead paint as a child? *

Yes No
Have you ever had prolonged exposure to asbestos? *

Yes No
Do you have any Tattos please check all that apply *

I do not have any tattoos I am happy with ALL my tattoos I regret my tattoos My tattoos are a source of stress I got my tattoos because I wanted to I love some of my tattoos and hate some of my tattoos
Have you ever? (Check All that Apply) *

been in a Fire been in a Flood been in a hurricane been in a monsoon been in a typhoon been in a tornado been in a motorcycle crash been in an automobile crash fallen off of a roof , ladder or height above 6 feet /2 meters nearly drowned had to be revived by CPR been tied up against your will been held down or immobilized against your will been locked in a closet or box against your will been buried alive been trapped in an elevator been shot at or shot by a gun been stabbed at or stabbed with a knife or sharp object been assaulted or hit with a blunt object such as a stick or bat been "jumped" or attacked by multiple people been trampled in a crowd been hit with fists been kicked been spanked with a belt been spanked by hand been slapped with an open hand been attacked by a dog, cat, bird or animal of any kind been sexually assaulted or raped been touched in a sexual manner without your permission been kidnapped been choked by another person been robbed at gun or knife point had your home broken into or burglarized had your identity stolen had your car stolen or broken into witnessed anyone else be beaten up or jumped witnessed anyone else die seen a dead body witnessed an animal or insect die that disturbed you killed an animal hunting killed an animal not hunting killed a person in self defense witnessed a suicide known anyone that committed suicide witnessed another person be sexually assaulted seen anyone lose a limb or body part (finger, arm ,leg, ear) Witnessed another person be shot or stabbed
What city/state/country did you grow up in? (If there are more than one, Please list them and the ages you were there)
Do you know what kind of birthing experience your biological mother had with you? *
Was your biological mother experiencing any trauma or drama in her own life from conception through her pregnancy with you? *
Who was your primary Care Taker (parent, guardian or other person that you spent the most time with) from 0-5 Years of Age?
Who was your primary Care Taker (parent, guardian or other person that you spent the most time with) from 5-10 Years of Age?
Who was your primary Care Taker (parent, guardian or other person that you spent the most time with) from 10-13 Years of Age?
Who was your primary Care Taker (parent, guardian or other person that you spent the most time with) from 13-18 Years of Age?
Who is your favorite parent?
Which parent did you feel closest to as a child?
Which parent do you feel closest to now?
Are your biological parents alive? *

Mother Yes Mother No Father Yes Father No
Do you have any Brothers/Sisters? If so, please list their ages. *
Do you have a favorite sibling? If so, which one?
Do you have a LEAST favorite sibling? If so, which one?
Do you have any children? What are their ages, genders? *
How did you feel when you found out you were expecting each child? *
How was the birth experience of each child? *
Have you ever been: *

In Jail Imprisoned Held Hostage/ Held Captive None of the above
How much time (in hours) would you say that you spend alone every day (not including sleep time)? *
Which best describes your daily amount of sleep *

0-2 hours 2-4 hours 4-6 hours 6-8 hours 8 or more hours
Do you normally feel well rested when you wake up? *

Yes No It is hit or miss
Do you look forward to sleep? *

Yes No If I didn't have to, I wouldn't If I could sleep all the time, I would
What’s Your ACE Score? And Your Resilience Score?

The CDC’s Adverse Childhood Experiences Study (ACE Study) uncovered a stunning link between childhood trauma and the chronic diseases people develop as adults, as well as social and emotional problems. This includes heart disease, lung cancer, diabetes and many autoimmune diseases, as well as depression, violence, being a victim of violence, and suicide.

For this part of the questionnaire we want you to keep track of how many "YES" answers you have out of 10 questions, you will be asked to enter the total 0-10.

Prior to your 18th birthday:
Did a parent or other adult in the household often or very often… Push, grab, slap, or throw something at you? or Ever hit you so hard that you had marks or were injured? *
Did a parent or other adult in the household often or very often… Swear at you, insult you, put you down, or humiliate you? or Act in a way that made you afraid that you might be physically hurt? *
Did an adult or person at least 5 years older than you ever… Touch or fondle you or have you touch their body in a sexual way? or Attempt or actually have oral, anal, or vaginal intercourse with you? *
Did you often or very often feel that … No one in your family loved you or thought you were important or special? or Your family didn’t look out for each other, feel close to each other, or support each other? *
Did you often or very often feel that … You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? or Your parents were too drunk or high to take care of you or take you to the doctor if you needed it? *
Were your parents ever separated or divorced? *
Was your mother or stepmother: Often or very often pushed, grabbed, slapped, or had something thrown at her? or Sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard? or Ever repeatedly hit over at least a few minutes or threatened with a gun or knife? *
Did you live with anyone who was a problem drinker or alcoholic, or who used street drugs? *
Was a household member depressed or mentally ill, or did a household member attempt suicide? *
Did a household member go to prison? *
Now add up your “Yes” answers. What is your ACE Score? *
_______________________

What’s Your Resilience Score?

Please select the most accurate answer under each statement:
I believe that my mother loved me when I was little. *

Definitely true Probably true Not sure Probably Not True Definitely Not True
I believe that my father loved me when I was little. *

Definitely true Probably true Not sure Probably Not True Definitely Not True
When I was little, other people helped my mother and father take care of me and they seemed to love me. *

Definitely true Probably true Not sure Probably Not True Definitely Not True
I’ve heard that when I was an infant someone in my family enjoyed playing with me, and I enjoyed it, too. *

Definitely true Probably true Not sure Probably Not True Definitely Not True
When I was a child, there were relatives in my family who made me feel better if I was sad or worried. *

Definitely true Probably true Not sure Probably Not True Definitely Not True
When I was a child, neighbors or my friends’ parents seemed to like me. *

Definitely true Probably true Not sure Probably Not True Definitely Not True
When I was a child, teachers, coaches, youth leaders or ministers were there to help me. *

Definitely true Probably true Not sure Probably Not True Definitely Not True
Someone in my family cared about how I was doing in school. *

Definitely true Probably true Not sure Probably Not True Definitely Not True
My family, neighbors and friends talked often about making our lives better. *

Definitely true Probably true Not sure Probably Not True Definitely Not True
We had rules in our house and were expected to keep them. *

Definitely true Probably true Not sure Probably Not True Definitely Not True
When I felt really bad, I could almost always find someone I trusted to talk to. *

Definitely true Probably true Not sure Probably Not True Definitely Not True
As a youth, people noticed that I was capable and could get things done. *

Definitely true Probably true Not sure Probably Not True Definitely Not True
I was independent and a go-getter. *

Definitely true Probably true Not sure Probably Not True Definitely Not True
I believed that life is what you make it. *

Definitely true Probably true Not sure Probably Not True Definitely Not True
How many of these 14 protective factors did I have as a child and youth? (How many of the 14 were “Definitely True” or “Probably True”?) *
Of these selected, how many are still true for me? *
Signature. By signing this form you agree that you have answered all of the above questions honestly and to the best of your knowledge and ability. You also agree that you are submitting this information for use by TahKole solely for the purposes of supporting you in your work directly with them on your self-development. This information will not be shared nor sold to any other parties. *

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Date *

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Date
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This is NOT an on-boarding call. >> All Information collected on this form is kept confidential and is shared with no one except for Tah Whitty and Kole Whitty.

You're All Set! Thank you!