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Wellbeing: Holistic Counseling
Intake Form
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Name
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Your answer
Phone
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Your answer
E-mail Address
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Your answer
Date
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DD
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YYYY
Describe your condition of health. Physical:
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Mental health:
Your answer
Emotional health:
Your answer
Spiritual health:
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Briefly describe what you are hoping to gain or let go of from this process.
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Your answer
Briefly describe where you are at spiritually including your concept of a Higher Power/God/Universe.
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Your answer
Have you had any severe illnesses?
Yes
No
Maybe
Other:
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Have you had any surgeries?
Yes
No
If yes, please explain.
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Are you currently taking any medications?
Yes
No
If yes, please explain.
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Are you currently being treated with a physician, chiropractor, therapist body worker, spiritual healer or other medical or therapeutic treatment? Please Explain.
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Emergency Contact Information (name, phone)
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Dates and times available for appointments:
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What causes you stress?
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