Intake Form

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date

Date of Birth

Age

Phone

Email

Referred by:

Describe any current or recent body problems.

Describe any current or past body issues.

Describe your general health.

Briefly give history of health and illness.

Describe any current addictions, including food, alcohol, and cigarettes.

Place of Birth

Siblings

Birth Order

In what kind of facility were you born?

Planned Pregnancy? Were you wanted- By your mother? By your father?

List any specific physical or emotional difficulties during mother’s pregnancy with you.

What do you know about your mother’s labor or delivery?

Describe the circumstances around your birth (early or late, forceps, anesthesia, caesarean, breech, induced, cord around neck, etc?)

Describe any miscarriages, abortions or fetal deaths before or after you.

Where was your father/or mother’s partner on the day you were born?

Were you breast-fed? If not, why?

Describe the attitudes of your parents, siblings, or other family members regarding your birth.

Describe your parent’s relationship- past & present. Any other significant care givers?

What did you like about your mother, father, caregivers?

What did you NOT like about your mother, father, caregivers?

Briefly describe your infancy and childhood.

List age & details of childhood injuries, surgeries, illnesses, accidents, and/or emotionally traumatic events.

Are you married or have you been married? Elaborate.

Describe current or most recent primary relationship:

How do you feel about your sexuality?

List name, age and sex for each of your children.

Describe any current or recent emotional issues.

List forms of past or present therapy. Describe any prior emotional process work.

What is your MOST negative thought about yourself?

What is your MOST negative thought about life?

What is your MOST negative thought about relationships?

Select the emotion that is EASIEST for you to express.

Select the emotion that is the most difficult or LEAST often expressed.

What are your major fears? How do you deal with fear?

What are your major angers? How do you deal with anger?

Briefly describe any spiritual or religious beliefs.

What would you like to accomplish with this work?

Any other information you would like to share that might be helpful in our work together?

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About Sarah

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