RELEASING THE PAIN AT THE SOURCE

Comprehensive Intake Form

All form fields are required; if any field does not apply to you please type in NA

First and last name

Date

Year

Month

Day

Phone

Address

Birthday

Year

Month

Day

What is your current relationship status:

Please describe the key romantic relationships in your history

If you are in a relationship, please state their name, length of relationship, and the main problems in relationship

If you are in a relationship, how would you rate this relationship on a scale of 1 - 10?

Do you identify as having a physical or mental disability or diagnosis?

Have you previously received any type of mental health services? If so, please state when; over how long with approximately how many sessions; where; and for what

Specify all medications and supplements you are presently taking, and, for what reason

Do you have a primary care physician? What is their name, and the clinic’s name and location

Please rate your current physical health

Please rate your current sleeping habits

How many days a week do you generally exercise?

Do you experience issues with your appetite or eating patterns?

Have you ever been hospitalized for longer than 24 hours? If so, for what?

Please list any physiological issues that you are currently affected by

Do you drink alcohol? How often and how much over a week?

Do you use recreational drugs? If so, what?

Have you ever experienced issues with Addiction? If so, when?

If yes, list your drugs/behaviours of choice

Have you attended a treatment plan or facility?

If so, where, when, and for how long?

Do you have current or past legal issues?

What is your current financial situation, current living situation, and any support system(s) you have in place?

Do you currently have suicidal thoughts? If so, what are they?

Have you ever attempted suicide in the past?

Have you ever experienced abuse in any of the following areas - Physical; Sexual; Mental; Emotional?

Please explain with who, what happened, and where it happened

Do you have thoughts or urges to harm another person? If so, with whom?

Please indicate on a scale of 1 - 10 how you feel on a regular basis

Were you adopted?

Please outline your PARENTS and include the following information for each person: 1) Name 2) Age/deceased 3) Occupation 4) Personality type 5) Your depth of connection with them

Please outline your SIBLINGS and include the following information for each person: 1) Name 2) Age/deceased 3) Occupation 4) Personality type 5) Your depth of connection with them

Please outline THE PEOPLE SIGNIFIGANT TO YOU and include the following information for each person: 1) Name 2) Age/deceased 3) Occupation 4) Personality type 5) Your depth of connection with them

Please describe the quality of your childhood up to the age of 12

Please describe the quality of your adolescent years (ages 13 - 18)

Please describe the quality of your adult life (from 19 to present day)

Please indicate the existence of the physical, mental, emotional conditions in your immediate and extended family

Please outline your academic history

Please outline your employment history (current occupation, length of time you have worked there, if you are happy in this position). Also, key jobs you have held in the past, length of time you held them, and reason for leaving the position

Do you consider yourself to be spiritual or religious? If so, please explain

Please list your strengths, healthy passions, and things that motivate you

Please list your weaknesses or things you otherwise would like to improve upon

Is there anything else you think that might be important that I should know about you?