Shamanic Services Intake Form
Please complete this form to the best of your ability.
Email address *
Name *
Your answer
Street, City, State, Zip *
Your answer
Phone Number *
Your answer
Gender *
Your answer
Preferred Gender Pronouns *
Your answer
Date of Birth *
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Relationship Status *
Your answer
Emergency Contact - First & Last Name *
Your answer
Emergency Contact Street, City, State, ZIP *
Your answer
Emergency Contact Best Phone Number *
Your answer
Emergency Contact Email *
Your answer
Discovery Information
If you are completing this form on behalf of the client, please provide answers from their perspective.

If you are completing his form on behalf of a minor, please modify the questions to fit the minor and be specific with details provided. This form must be completed by the legal guardian(s) of the minor or by the minor’s legal parent(s).

Some of these questions might seem “odd,” however, the answers help support the work we may do in our sessions.

If you are unable to type your answers below, feel free to use another document / paper to answer the questions.

1. Have you worked with a shamanic practitioner previously? *
If Yes, please provide dates and describe the work and situation you sought support for. *
Your answer
2. Have you worked with a shamanic practitioner * for this issue * previously? *
If Yes, please provide dates and describe the work and situation you sought support for. *
Your answer
3. Is there any ancestral, familial or historical significance to your name? For instance, are you named after a (deceased or living) family member, famous person (dead or alive), god or goddess, mythical being, etc? *
If so, please share: *
Your answer
4. What family of origin and immediate family members have passed in your lifetime? Please list the cause of each family member listed. *
Your answer
5. Please list family members that passed traumatically prior to your birth and any whose story is repeated or honored frequently in your family. Also include the cause of the passing. *
Your answer
6. List the number of pregnancies and dates of pregnancy. If you are male or the parenting partner at the time of conception or birth, list pregnancies you have fathered or been partner to: *
Your answer
7. List first names and birth dates of live births. If the child has passed, please indicate and include date and cause of passing: *
Your answer
8. Are your children named after a (deceased or living) family member, famous person (dead or alive), god or goddess, mythical being, etc? *
If Yes, please share: *
Your answer
9. Have you ever seen a therapist, mental health counselor or alternative therapist for emotional or spiritual help? *
If Yes, are you currently seeing a therapist, mental health counselor or alternative therapist for emotional or spiritual help? *
10. Please list dates or periods of time when you worked with a therapist, mental health counselor or alternative therapist for emotional or spiritual help? *
Your answer
11. Are you currently taking prescription medications of any kind? *
If Yes, please list each medicine and its purpose: *
Your answer
12. Do you take alternative supplements to help with your emotional, physical or spiritual well-being? *
13. Please list and describe any recurring or unresolved condition, illnesses, injuries or symptoms you have experienced in the recent years. *
Your answer
13. Please list and describe any recurring or unresolved condition, illnesses, injuries or symptoms you have experienced in the recent years. *
Your answer
14. Please list anything that may have occurred just prior to the onset of the condition *
Your answer
15. Have you seen a physician or helping professional about the condition you described in the previous question. *
If yes, what type of physician or helping professional have you seen for the condition? *
Your answer
16. Regarding any incident, injury, or illness that occurred just prior to the onset of the condition for which you are seeking support, please provide any additional information that may be insightful. *
Your answer
17. Do you have allergies of any kind? If so, please list and explain: *
Your answer
18. On a scale of 0 to 10, 10 being as much as humanly possible, provide a ranking for the level of self love you feel toward yourself today: *
19. Has this rating changed in the recent past? If so, describe: *
Your answer
20. If you have you suffered from any of the following in the past or present, please share details you feel are important for me to know: *
Your answer
21. Depression *
If yes, please share details you feel are important for me to know: *
Your answer
22. Post Traumatic Stress Disorder *
If yes, was it diagnosed by a physician? *
23. Dissociation *
24. Anxiety *
25. Panic Attacks *
26. Chronic Stress *
If yes, please describe: *
Your answer
27. Sleep Disorders *
If yes, what was the diagnosis? *
28. Going to Sleep *
29. Staying Asleep *
30. Anger Issues or Challenges *
31. Substance Issues *
32. Compulsive Behaviors *
If Yes, please specify or describe: *
Your answer
33. Chronic Illness *
If Yes, please provide details and include dates: *
Your answer
34. Please list dates and details of all surgeries, procedures, and events where you received anesthesia *
Your answer
35. Please list dates of terminated pregnancies *
Your answer
36. Please list dates of miscarriages *
Your answer
37. Please list birthdates of children you have adopted and any details you think are important *
Your answer
38. Do you experience negative self-talk? *
If yes, what is the theme of negative self talk? *
Your answer
When does it happen? *
Your answer
Describe what it sounds like *
Your answer
Are there different voices? If yes, please describe and provide any other details you feel are important *
Your answer
39. Do you have a sense that something is missing? *
If yes, please describe *
Your answer
40. Do you experience a sense of shame? *
If Yes, please describe: *
Your answer
41. Do you experience procrastination? *
If Yes, please describe: *
Your answer
42. Do you experience mood swings? *
If Yes, please describe the 1) range of the mood swings, 2) what triggers them and 3) if they happen more often during certain times of day, of the week, seasons, holidays, etc: *
Your answer
43. Paranormal experiences? *
Please describe, if yes. *
Your answer
44. Chronic bad luck? *
If yes, please describe: *
Your answer
45. Traumatic Loss *
If yes, please describe: *
Your answer
46. Do you have a spiritual foundation? *
Please describe: *
Your answer
47. If you have other health issues I haven't asked about, please list kind and date: *
Your answer
48. What would you like to have differently in your life? *
Your answer
48. What would you like to have differently in your life? *
Your answer
49. What else would you like to share with me, even if it sounds weird? *
Your answer
50. As you completed this intake, is there anything I failed to ask that you believe could be important to the success of our work together? *
Your answer
51. What do you think is going on? Please describe any thoughts you have about what you are experiencing. *
Your answer
I have answered the questions and provided the information with complete accuracy and transparency. I understand that this information is important to understanding the client, their situation and to providing the best care possible.
Client or Guardian Signature (your signature is your typed legal name) *
Your answer
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