you are heard - you are seen - you are ready-

All information is strictly confidential and will only be viewed by your therapist.

Name

First Name

Last Name

Date of Birth

YYYY

Phone Number

(###)

###

####

Gender

Female

Male

Other

Occupation

Referred By

Emergency Contact

Name, Relationship to you and their best Contact Number/ Email Address

Relationship Status

Do you have any children/ dependents?

What do you do to have fun and/ or express your creativity?

List the main current stressors that you are currently experiencing?

LIFESTYLE

Current Sleep Patterns

Do you feel rested?

Yes

What type of environment did you grow up in?

What was your parents relationship like, how's your relationship with them? Siblings? How was school etc?

Are there any reoccurring patterns in your life?

Have you tried any other therapies?

If so please list below.

Is there anything else I should be aware of to ensure that you feel comfortable within then session/s?

Do you have any certain triggers, bad previous experiences or preferences during our time together?

Describe your main concerns or goals for attending these sessions.

How do you want to feel or what do you want to achieve out of the sessions/ program?

To what degree do you feel capable of committing yourself to your healing journey?

1= Lowest 10 = Highest

FAMILY HISTORY

Family Mental/ Physical Illnesses/ Addictions

PERSONAL HISTORY

Medical/ Mental Health Diagnosis

Supplements and Substances

List all supplements, medications and substances that you are currently taking.

you are heard - you are seen - you are ready- you are heard - you are seen - you are ready-