Please Note:The start of this intake is focused on physical questions and the emotional intake is later – please note any and all issues even if they are not your primary reason for consultation to best provide a holistic view of you as a person.
Skip questions that are not applicable, or ask me if questions are unclear or need further discussion. You are never limited to a specific length response.
You may choose not to answer any question. You may also write – prefer to discuss in person as (PDP) Your answers will be saved and I will not be able to edit these, but we can also continue to add provider notes after your responses, as we work together.
I will not address everything on this intake with you but it will be included in creating your personalized therapeutic plan.
It’s long, I know, but hang in there… and Welcome to integrative healthcare, where all your information is important!
SITUATION AND EXPECTATIONS
Please describe generally the health problems that you are having now in your own words and prioritize them by concern or intensity of issue. (you will have a chance to further describe specific symptoms) What is the main intention of your sessions? What are your hopes and goals in working together?
What do you think caused / is causing this problem? What do you think will help you? How do you hope I will help this problem? What are you currently doing to deal with this challenge? Do you have any current diseases/illness or diagnoses? Do you have imaging/labs/or other diagnostics in your possession? Are you under treatment? What have they suggested? Please describe your symptoms: Did your symptoms begin suddenly or gradually? Is the symptom constant or intermittent? How have the symptom(s) changed since they began? Do your symptoms interfere with your sleep? Are you experiencing pain now? How would you describe your pain? (emotional, physical, dull, sharp, piercing, electric, constant, intermittent, suffocating, located in the same place, pain moves around, etc) On a scale of 1-10 (1= least pain, 10= most pain), rate the intensity of your pain. Do you have inflammation that you know of? How do you generally care for yourself to maintain your physical and emotional health? Do you currently take any medication for this or other issues? If yes, what, dosage and as of when? Are you taking any supplements? If so what and how often/dosage?
This next section pertains only to people with/or having had vaginas. Otherwise please skip
If so, for each pregnancy what were the outcomes?
Eg: Did you carry to term, vaginal or C/S birth, deliver pre or post dates, abort, miscarry, stillbirth, other?
Continued general questionnaire
Do you sweat? Do you get headaches? Do you have pets or animals in your life? If so, tell me about your interactions with them: eg: horses – do you ride/groom them, dogs – what breed/do you walk on leash, injured or old pet you are caring for? etc. Do you have children (ages, gender, special needs, other)? If so, how does this manifest in your life? Have you had any major injuries, or acute illnesses? If so what and when? Do you have a family history of this kind of condition or symptom? What is your stress level from 1-10 (one being no stress, 10 being overwhelming) What is causing your stress? Have you ever experienced trauma that you care to mention?
This could be surgical, medical, emotional or physical or sexual abuse, it could be oppression or discrimination, violence, or combat, or any other form of trauma that you feel has impacted you and that you may still be processing – as we often do.
Do you recall the events or trauma you mention? Have you sought help for this and are you in any treatment now (therapeutic sessions or medications?) Please mention if there are things that could improve our work together such as avoiding any form of assist or contact, breath work, needing to be in an open space, lighting, having someone else present, doing sessions virtually, etc… We generally will not be talking about your trauma. But are there aspects of your trauma you would like to focus on, or conversely, not discuss or mention? Are you aware of this or other traumas having taken hold of areas of your body (eg: car accident knee pain or headaches triggered when find self in closed spaces, panic attacks at sunset, etc) Is there anything else you’d like to tell me about what is going on in your life? Lastly, what brings you joy? Tell me about that…
Thank you for taking the time to fully complete this in-take form.
Please note that as a mandatory reporter, I will keep sessions with minors and vulnerable adults confidential as well, outside of any information I receive related to suspected abuse.
Please know that your personal information will be kept confidential and stored with the utmost regard. I am honored to be entrusted with your care and look forward to working with you.
In health and kindness,