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Intuitive Soul Support Form

This intake form is to be completed by all new clients. The answers you provide will become part of your confidential records.

Should you have any queries, or require assistance with any of the below questions, please feel free to ask your therapist.

First Name

Date of Birth

Home Tel No:

Work Tel No:

Last Name

Address

Mobile Tel No:

Email

Have you had any previous treatment for psychological issues?

If yes, please give details - i.e. when, where, how long, provider name, medications etc

Are you currently taking (or in the recent past, taken) any prescription or over-the-counter medications?

If yes, please give details:

Does anyone in your family (blood relatives) suffer with any psychological problems?

If yes, please give details:

Do you drink alcohol?

If yes, please give details – how much, how often, any blackouts, etc

Do you use any recreational drugs?

If yes, please give details – what drugs, how often, last use etc.

Have you ever suffered from any type of eating disorder?

If yes, please give details:

Do you have any work-related problems / difficulties in school?

If yes, please give details:

Do you have a history of trauma (any kind of abuse, neglect, victim of natural or other disaster etc)?

If yes, please give details:

Symptoms Checklist

Sleep

No problem

Not enough

Trouble getting up

Nightmares

Too much sleep

Appetite:

No problems

No interest

Increased appetite - Carbohydrate craving

Energy:

Normal

Increased

Low

Up and down

Interest in sex:

Normal

Increased

Low

Concentration:

Normal

Somewhat difficult

Poor

Terrible

Memory:

Good

Some difficulty remembering

Poor

Depressed or Sad:

All of the time

Most days

Some days

Not at all

Suicidal thoughts:

All of the time

Most days

Some days

Not at all

Past suicide attempts

If yes, please give details:

Anxiety:

All of the time

Most days

Some days

Not at all

Panic Attacks:

Frequently

Occasionally

Not at all

Anger/Irritation:

All of the time

Most days

Some days

Not at all

Any other Comments:

Read the Privacy Policy of April 21st 2018

By using this form you agree with the storage and handling of your data by this website.

Thank you. Emily Teague

INTUITIVE SOUL SUPPORT CLIENT INTAKE FORM

ET

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