Confidential Client Intake Form

The information you provide here will be kept confidential and will be helpful in knowing how best to support you. Please answer each item to the best of your ability.

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Your Client Intake Form was successfully sent

Name

Phone Number

Address

City

State

Zip

Date of Birth

Gender

Occupation

Emergency Contact

How did you hear about me?

How did you hear about me (if you chose “other” above)?

What, if any, medications are you taking?

Have you ever been in psychotherapy, counseling or coaching before? If yes, please give the name of the therapist(s), which form of therapy or counseling was offered, the year(s) you saw them (e.g., 2008 – 2009), and the nature of the difficulty at the time.

Have you ever been hospitalized for mental or emotional difficulty? If yes, please give the year(s) and the nature of the difficulty at the time.

Please share any previous or current diagnoses given by a professional.

Have you ever been suicidal in the past or attempted suicide? If yes, when?

Do you or anyone in your family have a history of substance abuse? If yes, please specify.

Do you have any medical condition(s) of which I should be aware?

Please share a summary of the circumstances that led you to seek support at this time.

Please share what you hope to achieve from working with me.

Please share your family details… children, spouse, etc.

Please share your ancestral lineage and your current understanding of it.

Fees

My standard rates are $150/hour.

The first, 30-minute consultation is complimentary/free.

If these fees are prohibitive, please send me a message explaining your situation. I am open to renegotiation anytime so our exchange feels sustainable for us both. I ask that clients commit to 4 sessions before deciding to continue.

Cancellation Policy

I am only able to offer a limited amount of appointments per week. The appointment time I save for you is specifically for you and while I often maintain a wait list, I cannot book someone at the last minute. Appointments canceled without at least a 24-hour notice will be subject to a $75 cancellation fee for the first appointment missed and the full fee thereafter. We ask that you please reschedule or cancel at least 1 day before the beginning of your appointment.

Consider this…

If any difficult feelings have come to the surface from filling out this form, please take a deep breath and remember that you are safe. Consider going for a walk in nature or calling a trusted friend to share what has arisen. Offer yourself some appreciation for the courage to complete this form.