Client Intake Form

Becca Williams, RDN

My ability to draw meaningful insights into your current well-being and ways to enhance it relies greatly on you responding thoughtfully and accurately to these questions.

When I can thoroughly evaluate all factors and address them comprehensively, it becomes the most effective way for me to support your emotional well-being.

Please rest assured that all information you share here will be kept in full and absolute confidentiality.

Important:

Please schedule your one-hour personal session with me at your earliest opportunity.

Be sure to have this form completed and submitted at least 48 hours before we meet.

I’ll see you soon,
Becca

Schedule Your Session

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Email*

Name*

First Last

Phone

(INCLUDE COUNTRY CODE)

Add Becca +351 962-278-251 to your contacts and please send your name/say hello to Becca on Whatsapp.*

We use this for fast communication and to make a group, if applicable.

Done

Will do within 48 hours

Refuse

Preferred Pronouns*

He / Him / His

She / Her / Hers

They…

Other

Birthday

Month

Day

Year

How did you hear about Becca? (Please be specific)*

A Friend referred me

Internet Search

Social Media

Retreat Guru

Podcast or Interview

Other

If a friend referred you, please provide their name so I can thank them.*

Who was the host or writer?*

What social media platform(s)?*

Please explain:*

Plant Medicine History

Describe your experience with psychedelic substances.*

How many times have you recreationally used consciousness altering substances? Which ones?*

How many times have you taken consciousness altering substances in a ceremonial setting? Which ones?*

Health and Social Information

Have you ever had psychotherapy or counseling?*

Yes

If yes, what kind?

When?

Additional comments?

Are you currently on medication to manage your moods (prescription or otherwise)? If yes, please list:

Please list any persistent physical symptoms or health concerns, including those that make hinder your mobility.*

Including blood pressure, heart conditions, blood sugar issues, or anything else relevant.

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.

Do you have any food allergies/sensitivities (please be specific)?

This will help us with menu planning.

Are you having any problems with your sleep?

Yes

If yes, check where applicable:

Sleeping too little

Sleeping too much

Poor Quality Sleep

Disturbing Dreams

Other…

Do you exercise?*

Yes

What kind of exercise and how often?*

Do you consume alcohol?*

Yes

If yes, what kind of alcohol and how many drinks per week?

(wine, beer, hard spirits)

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

Do you currently smoke cigarettes or use other tobacco products?*

Yes

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?*

Yes

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:

Have you ever experienced any of the following?

Extreme depressed mood

Dramatic mood swings

Extreme anxiety

Phobias

Sleep disturbances

Unexplained memory lapses

Alcohol/Substance abuse

Frequent body complaints

Eating disorder

Repetitive behaviors (e.g. frequent checking, hand washing)

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*

Family Mental Health History

Mother

Depression

Bipolar Disorder

Anxiety Disorder

Panic Attacks

Schizophrenia

Alcohol/ Substance Abuse

Eating Disorders

Learning Disabilities

Trauma History

Suicide Attempts

Chronic Illness

Father

Depression

Bipolar Disorder

Anxiety Disorder

Panic Attacks

Schizophrenia

Alcohol/ Substance Abuse

Eating Disorders

Learning Disabilities

Trauma History

Suicide Attempts

Chronic Illness

Sibling

Depression

Bipolar Disorder

Anxiety Disorder

Panic Attacks

Schizophrenia

Alcohol/ Substance Abuse

Eating Disorders

Learning Disabilities

Trauma History

Suicide Attempts

Chronic Illness

Other Relatives

Depression

Bipolar Disorder

Anxiety Disorder

Panic Attacks

Schizophrenia

Alcohol/ Substance Abuse

Eating Disorders

Learning Disabilities

Trauma History

Suicide Attempts

Chronic Illness

If "Other Relatives," please list the relationship here:

Occupation Information

Are you currently employed?*

Yes

If yes, are you happy with your current position?

Please list any work-related stressors, if any:

Are you retired?*

Yes

How are you finding retirement?

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?

Emergency Contact

First Name

Last Name

Phone Number

Photography Consent

We may take photos/video for promotional purposes so we can share this transformational work with others (no personal details will be shared without your consent). Do you consent to the use of your likeness and image in photographs or audio-visual recordings taken during the course of the event?

I understand that I will not be entitled to receive any payment in exchange for the use of this.*

Yes, I hearby consent.

Yes, with stipulation: not the use of my face.

No, I do not consent.

Undecided – let me decide later.

Name

This field is for validation purposes and should be left unchanged.