CONFIDENTIAL INTAKE SHEET

Name______email: ______

Address ______

Telephone: Day ______Evening ______

Date of Birth ______Place of Birth ______

Occupation ______Marital Status ______

If married now, or in a committed relationship, howlong? ______

Children: names, ages, still living with You? ______

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What do you want to accomplish in our work together?

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Your understanding of cause ______

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Who else does it affect; ______

How will you know you are better ______

How will other know you arebetter______

What would you be willing to let go of, or give up to handle these situations?

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What are the reoccurring patterns in your life and how are they affecting you? How long have you continued these patterns (behaviors, relationships, types of jobs, etc.), and what was happening in your life when these patterns first appeared?

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Have you ever been in counseling or psychotherapy? If so, how long and with what results? ______

Have you ever been hypnotized? If yes, for what reason?

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How did you find out about us?

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In what setting(s) did you grow up? (City, rural, small town, military or other)

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Were you adopted? If so, at what age?

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How would you describe your childhood, including your home and school situations?

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Do you have early childhood memories before the age of 10?

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Do you Blush Easily? ______

Do you smoke? ______

Do you remember any childhood traumas? Please describe.

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Describe your relationship with your mother and father or other primary care adults in your life. Are they still living? Is there anything about them or your relationship that is important to know?

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What is your parent's marital status: (Still married, divorced, mother/father remarried, etc.)

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Other adults who had a part in your upbringing: (family members besides brothers and sisters, important teachers or role models-both good and bad). What was your relationship with them?

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Names and ages of your brothers and sisters. Are they still living? Is there anything specific about your relationship with them that is important to know?

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Do you make friends easily? ______

Do you think about harming or killing yourself?______

Do you tend to repress your feelings?______

Do you feel anger or resentment towards any person in your life? Why?

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Do you ever have Panic attack symptoms (lasts minutes)
Shortness of breath / Dizziness / Numbness / Shaking / Unusual sweating / Fear Death / Fear of crazy
Choking feeling / Chest pain/ discomfort / Racing heart / Nausea / Feeling unreal/out of touch v/s body / Hot/cold flush

Other general Anxiety Symptoms

On edge / Poor conc. / Sleep difficulty / Irritability / Restlessness / Muscle tension

Parnoia Yes --- No ------High ------Low ------

Fears! Phobias: Any problem with the following:

Flying / Germs / Drugs / Sacred Things / Open spaces / Rats I Vermin / Flames / Blushing / Failure
Ghosts / Work / Insanity / Suffering / Enclosed
Spaces / Snakes / Water / Knives / Responsibility
Superstitions / Odours / Cancer / Corpse / Animals / God / Crowds / Heart Disease
Death / Dirt / Injections / Disease / Thunder / Birds / Stared at / Electricity
Darkness / Blood / Snails / Vomiting / Spiders / Insects / Churches

Compulsions

Do you ever find yourself compulsively, checking things e.g.: Cooker knobs, light switches, house security, or counting, retracing steps, etc. ______

Obsessive Behavior

Ceremonial or ritual about your daily habits - something that goes beyond the realm of habit and reaches almost into the realm of magic I superstition -washing your hands half a dozen times before a meal? Etc.

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Depression symptoms:

Chronic pain that fails to respond to typical treatment / Fatigue weakness, lack of enthusiasm, decreased energy / Restlessness, irritability
Eating disturbance - usually loss of appetite and weight / Loss of interest and pleasure in activities once enjoyed / Low self-esteem or guilt
Thoughts of suicide and death / Insomnia, early awakening, difficulty getting up / Feelings of sadness, hopelessness
Diminished ability to think or concentrate

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Have you ever had an abortion or a miscarriage? If yes, how many? How long ago?
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Was religion/spirituality an important part of your upbringing? Your life now?
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Have you ever had a near death experience? If so, please explain.

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Have you ever had a psychic experience? If so, please explain.

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Do you remember your dreams? Have you had any out of body experiences?

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Are you following any regular disciplines? Meditation, yoga, martial arts, exercise, etc.?

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Do you seem to notice or experience anything as a constant in your life, and if so, does it prevent you from experiencing anything else in particular?

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What is your work situation? Do you enjoy your job and the people you work with?

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MEDICAL INFORMATION

Doctor's name ______Telephone ______

Are you currently under a doctor's care? If so, for what?

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Are you currently taking any medications? If so, what kinds?

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Do you have a history of:

__Allergy/asthma __Heart disease__Chronic Fatigue Syndrome

__Alcohol abuse __Drug use __Smoking __Eating disorders __Chronic pain

__Fainting/blackouts __Insomnia __High blood pressure __Shortness of breath

__Cancer __Dyslexia/Learning Difficulties __Diabetes __Hypoglycemia___Aids

If you checked any of the above boxes, please provide further information. Also include any other physical problems you may have experienced, including those of ear, eye, nose or throat, as well as any conditions of the spinal column, nervous system, reproductive system or elimination system.

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