Client Intake Form Step 1 of 6 16% Name* First Last GenderPlease selectFemaleMaleNon-binaryDate of Birth* Year Month Day Email* Enter Email Confirm Email Phone*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Starting SessionsWhat are the central issues in your life at this time?Describe what you hope to accomplish in our work together:Therapy HistoryHave you been in counselling for this or other concerns in the past? yes no Please describe briefly about the counselling. Family DetailsWere you adopted? yes no At what age were you adopted and under what circumstances?As far as you know, did your mother or you experience difficulties during her pregnancy, labor, or shortly after your birth? yes no If yes, please explainIf your parents divorced, split up, or separated, at what age were you when this happened?Personal Medical and Mental Health HistoryAllergies me past me current Asthma me past me current Eczema me past me current Migraine me past me current Pregnancy me past me current Stroke me past me current Sexual Problems me past me current Anxiety me past me current Bipolar me past me current Self-Harm me past me current Fibromyalgia me past me current High Blood Pressure me past me current Irritable Bowel Syndrome me past me current Osteoporosis me past me current Epilepsy or seizures me past me current Learning Disability me past me current Thyroid Disease me past me current Depression me past me current Panic Attacks me past me current Borderline Personality Disorder me past me current Glaucoma me past me current ADHD me past me current Crohn’s Disease me past me current Cancer me past me current Arthritis me past me current Heart Disease me past me current Eating Disorder me past me current Phobias me past me current Suicidal me past me current Obsessive/ Compulsive (OCD) me past me current Other conditions not listed above:Did you have any surgeries in the past? yes no Please list any surgeries you’ve had and their dates:Are you currently taking any prescription medications? yes no Please list the prescription medications:Are you currently taking any supplements? yes no Please list the supplements: Personal Medical and Mental Health HistoryScreen timeNumber of hours of screen time per day (phone + computer + video games + TV)please selectless than one hour123456789101112131415Substance Use Currently or In Past TobaccoPlease choose all relevant options! I currently use it. I quit using it. I used it in the past. I have never used it. Current use of tobacco My use is interfering with my life. I feel the need to cut down on use. Past use of tobacco My use interfered with my life in the past. I felt the need to cut down on my use in the past. AlcoholPlease choose all relevant options! I currently use it. I quit using it. I used it in the past. I have never used it. Current use of alcohol My use is interfering with my life. I feel the need to cut down on use. Past use of alcohol My use interfered with my life in the past. I felt the need to cut down on my use in the past. Recreational DrugsPlease choose all relevant options! I currently use them. I quit using them. I used them in the past. I have never used them. Current use of recreational drugs My use is interfering with my life. I feel the need to cut down on use. Past use of recreational drugs My use interfered with my life in the past. I felt the need to cut down on my use in the past. SleepHours of sleep in average per night:Quality of sleepDo you struggle with insomnia? yes no If yes, what methods have you tried to address your difficulty sleeping and are they working?Physical Activity and Energy LevelWhat do you do for physical activity and with what frequency?On a scale of 0 to 10, what is your current energy level (0 = completely drained; 10 = very energetic)?please select109876543210StressOn a scale of 0 to 10, what is your current overall stress level (0 = none; 10 = stressed to the max)?please select109876543210Biggest sources of stress in life currently:How do symptoms of stress show up in your body?How do you typically cope with stress?Relaxation, Joy, and SupportWhat activities recharge your batteries?What/who are the biggest sources of joy in your life?Who do you rely on for emotional support in your life? Adverse Events in ChildhoodWhile I was growing up, during my first 18 years of life….I experienced physical abuse (e.g., pushed, grabbed, slapped, beaten, or harshly punished) from a parent or other person. yes no How much did this experience bother you at the time?0 = not at all to 5 = very muchplease select012345How much does this bother you now?0 = not at all to 5 = very muchplease select012345I experienced sexual abuse (e.g., touching, molesting, fondling, or intercourse) from a parent or other person. yes no How much did this experience bother you at the time?0 = not at all to 5 = very muchplease select012345How much does this bother you now?0 = not at all to 5 = very muchplease select012345I experienced emotional abuse (e.g., humiliation, threats, boundary violations, blame, bullying) from a parent or other person. yes no How much did this experience bother you at the time?0 = not at all to 5 = very muchplease select012345How much does this bother you now?0 = not at all to 5 = very muchplease select02345I experienced neglect (e.g., real or threatened abandonment, failure to provide essentials) from a parent. yes no How much did this experience bother you at the time?0 = not at all to 5 = very muchplease select012345How much does this bother you now?0 = not at all to 5 = very muchplease select012345I witnessed family members suffering from physical, sexual, or emotional abuse. yes no How much did this experience bother you at the time?0 = not at all to 5 = very muchplease select012345How much does this bother you now?0 = not at all to 5 = very muchplease select012345My parents separated or divorced. yes no How much did this experience bother you at the time?0 = not at all to 5 = very muchplease select012345How much does this bother you now?0 = not at all to 5 = very muchplease select012345A parent, sibling, or other important person in my life died. yes no How much did this experience bother you at the time?0 = not at all to 5 = very muchplease select012345How much does this bother you now?0 = not at all to 5 = very muchplease select012345A parent or other adult in my home was an alcoholic or drug addict. yes no How much did this experience bother you at the time?0 = not at all to 5 = very muchplease select012345How much does this bother you now?0 = not at all to 5 = very muchplease select012345A parent or other adult in my home was depressed, mentally ill, or suicidal. yes no How much did this experience bother you at the time?0 = not at all to 5 = very muchplease select012345How much does this bother you now?0 = not at all to 5 = very muchplease select012345I experienced discrimination because of my race, gender, appearance, sexual orientation, religion, or other factors. yes no How much did this experience bother you at the time?0 = not at all to 5 = very muchplease select012345How much does this bother you now?0 = not at all to 5 = very muchplease select012345Other childhood difficulties that are not captured above: Adverse Events in AdulthoodHave you faced significant challenges as an adult (e.g., serious illnesses, accidents, losses, adult trauma, abusive or un-stable relationships)? yes no If yes, briefly describe:Did I miss anything?Is there any other information you would like me to know about you at this time that isn’t captured above? yes no If yes, briefly describe:Disclosure Form and AgreementsI understand during breathwork or open sessions touch may be used to help facilitate greater body awareness, support the development of emotional resources and release of traumatic stress. I can refuse touch at any time. yes I understand that whatever I discuss is confidential; however it is required by law to release confidential information if: 1) a child or vulnerable adult is experiencing physical abuse, sexual abuse, or neglect, 2) I intend to harm myself or others, 3) a court order has been issued requiring release of confidential infor-mation to a lawyer or judge. yes If I am unable to keep an appointment, I will notify Prema at least 24 hours in advance. I understand that I will be charged a regular full session fee for scheduled sessions if I don’t show up for or call/email to cancel with appropriate notice. yes I would like to be added to Prema & Sacred Inquiry’s mailing list to receive periodic emailed updates, class registration alerts, and newsletters (your e-mail address will not be shared with others and you may opt out at any time). yes I have read the above information and have had an opportunity to ask questions to clarify my understanding of the information. I understand that I have the right to refuse or terminate sessions at all times, or to refuse touch, Somatic Experiencing® techniques, or any other intervention proposed. I have read the above informed consent, understand, and agree to it.* yes NewsletterThe Sacred Inquiry Newsletter Sign me up! Please review the information below before submitting the form. If you would like to make any changes use the "Previous" button at the bottom of the page. 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