New Client Intake Form I am interested in * Choose which option is right for you... Individual Therapy Life Coaching Couples Counseling Psychedelic Assisted Therapy Name * First Name Last Name Email * Phone (###) ### #### Emergency Contact What are your goals for therapy? Can you tell me a little bit more about yourself? How many people are in your household; and who makes up your household? What kind of support system do you have? Are you married or in a relationship? If so, for how long? Do you have family and friends that you are close with? If you have children, what are their genders and ages? Could you tell me what you see as your strengths and weaknesses? Do you have any special interest and hobbies? What do you do for fun? What do you do to relax? How do you handle stress and difficult situations in your life? What do you find helpful, and what have you tried that is not helpful? Could you tell me about your job, if you have one, as well as your work history, and educational background? How are things for you financially? Do you have any financial concerns? Do you have any spiritual beliefs; and if so, could you tell me about them and how they fit into your life? Have you ever been in counseling before? If so, would you mind sharing a little bit about your experience so I know what you focused on, what helped and what didn’t help? Is there any particular style or approach that you feel fits you best or anything you think would be helpful for me to know? Have you ever been given any mental health diagnoses (i.e. ADHD, depression, anxiety)? If so, when were you diagnosed and who diagnosed you (i.e. primary care physician, psychiatrist, therapist)? Are you currently taking any psychotropics (medications to manage mental health symptoms)? Do you have any health concerns or chronic conditions? If so, would you mind sharing more about them? Do you take any medications for physical health purposes? Do you have any concerns about alcohol or other substance usage? Do you ever feel unsafe or threatened in any way in your present living situation? Have you ever experienced any physical, emotional, mental, or sexual abuse in the past? If so, and you are comfortable, would you mind sharing a little bit about your experience and any help you received afterwards? Do you have any time frame in mind regarding how long you would like to be in counseling for, or is that open ended? Some people remain in counseling for years, while others plan to try it for weeks or months. I just like to ask so I know what your expectations are. If you haven’t thought about that, that’s okay. I think it’s always best to just see how things flow. There is no time limit here! Thank you!I will be in touch with you shortly
