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

Client Information Form

Becca Williams, RDN

Please take a moment to answer each question as thoughtfully and accurately as you can to help me better understand and support your emotional well-being.

All information you provide is held in full and absolute confidentiality.

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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

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?

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