INTAKE QUESTIONNAIRE
The information you provide will be kept confidential. Feel free to add any other information you feel may be useful. We will review this information and together will create a plan that will best support your personal goals. Please contact me with any concerns prior to completing this questionnaire.
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Full Name *
Birth date *
MM
/
DD
/
YYYY
Telephone *
Email Address *
(mailing) Street Address
City, State, Zip (Postal Code) *
Local Emergency Contact - Full Name *
This is the person I will contact if I have a concern about your wellbeing or the wellbeing of others.
Local Emergency Contact - Relationship *
Local Emergency Contact - Telephone *
Education
Current Profession or Vocation *
Employer
Sexual Orientation *
Required
Gender Identity/pronouns *
I am currently... *
Please list current health concerns and history for significant accidents, surgeries, illness or medical hospitalizations: *
Please list current Medications/Supplements/Herbs: *
What substances do you partake in regularly? *
Required
Tell me about your relationship with the above substance(s) (if any) Any history of addiction? *
I request that you do not attend an appointment with me while under the influence of any non-prescription mind-altering substances.
Are you attending a UU Congregation? *
Since I am fellowshipped as a UU minister, I need you to tell your minister (if you have a UU minister) that you are pursuing spiritual direction with me.
Please indicate how you prefer to pay
Preferred
Possible
Impossible
Zelle (usually your bank)
Cash App
GooglePay
Venmo
Transferwise (non-US$)
ACH (Direct bank transfer)
How did you learn about me
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