Client Intake Form Full [latest] | Emotional Liberation with Becca Williams

Personal Details

Name

Email Contact

Health and Social Information

Have you ever had psychotherapy or counseling?

If yes, what kind?

When?

Additional Comments?

Please list any persistent physical symptoms or health concerns (e.g. chronic pain, headaches, hypertension, diabetes, etc)

Are you currently on medication to manage a physical health concern? If yes, please list

List all vitamins, minerals and other nutritional supplements that you are currently taking

Are you having any problems with your sleep?

If yes, check where applicable

Sleeping too little

Sleeping too much

Poor quality sleep

Disturbing Dreams

Or comment below with more details

Do you exercise and what kind of exercise?

Approximately how often?

Are you having any difficulty with appetite or eating habits?

If yes, check where applicable

Eating less

Eating more

Bingeing

Restricting

Have you experienced significant weight change in the last 2 months?

Do you consume alcohol?

If yes, how many drinks per week?

Do you have any feelings around your alcohol consumption and why?

Do you smoke cigarettes or use other tobacco products?

Do you have suicidal thoughts?

Frequently

Sometimes

Rarely

Never

Have you had suicidal thoughts in the past?

Frequently

Sometimes

Rarely

Never

Suicidal attempts? If yes, when?

Are you currently in a romantic relationship?

If yes, how long have you been in this relationship?

On a scale of 1-10 (10 being the highest quality), how would you rate your current relationship?

In the last year, have you experienced any significant life changes or stressors? If yes, please explain

How important is religion or spirituality to you?

Do you meditate?

Never

Occasionally

Often

How much control do you feel you have over your current state of health? Rate 1-10 (10 being the highest level of control)

Do you ever have homicidal thoughts? Please comment

Occupation Information

Are you currently employed?

If yes, are you happy with your current position?

Please list any work-related stressors, if any

Other Information

What do you consider to be your strengths?

What do you like most about yourself?

What are effective coping strategies that you have learned?

Data consent *

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My ability to draw effective conclusions about your present state of well-being and how to improve it depends, to a significant extent, on your ability to respond thoughtfully and accurately to these questions.

Accurately assessing all the factors and comprehensively addressing them is the best way to support you in improving your emotional health.

Information you provide here is held in full and absolute confidentiality.

Personal Details

Health and Social Information

Family Mental Health History

Occupation Information

Other Information