Trauma / Conversion Disorder Intake Form
In preparation for any work we do together, it would be helpful if you could fill out the following form. I also have a few recommendations on materials for you to review.

If your symptoms are due to trauma(s) related to any time of your life where you felt the fear of or actually experienced the trauma of shame, abandonment, rejection or betrayal, I highly recommend reading The Mind Body Code by Dr. Mario Martinez. Copy and paste the following link into a web browser to order the book on Amazon: https://www.amazon.com/MindBody-Code-Beliefs-Longevity-Success/dp/1622031997/ref=pd_sim_14_1?ie=UTF8&dpID=41J%2BrUGW3qL&dpSrc=sims&preST=_AC_UL160_SR107%2C160_&psc=1&refRID=PTQ3JP1SDNS4ZWNE1RJW/mymindmypick-20

You can get a good taste of the book and a really useful self help technique by listening to this Sounds True Podcast. Copy and paste the following link into a web browser: http://www.soundstrue.com/store/weeklywisdom/?page=single&category=IATE&episode=10111

There is also a book called The Body Keeps Score that can give you an idea about how our bodies are affected from a wide variety of traumas. You can listen to the audiobook version on Youtube. Just copy and paste the following link into a web browser: https://youtu.be/53RX2ESIqsM

Email address
What is your first and last name?
Your answer
Home Address:
Your answer
Birth date:
MM
/
DD
/
YYYY
When did you first notice these symptoms?
Your answer
Have your symptoms changed over time and if so how?
Your answer
How severe are your symptoms?
Mild
Worst you could imagine
Have you recently experienced significant stress or trauma?
Your answer
What do you think may be causing your symptoms?
Your answer
Please list any symptoms you're experiencing, including any triggers you know of as well as symptoms that may seem unrelated to the reason for your appointment but you think are important for me to know:
Your answer
Have you been diagnosed with any other medical conditions or mental health problems?
Your answer
Please list key personal, family and social information, including any major stresses or recent life changes (brief bullets are fine):
Your answer
Have any of your close relatives been diagnosed with mental health problems?
Your answer
Please list all medications, vitamins or other supplements you're taking:
Your answer
Do you use alcohol or recreational drugs? How often?
Your answer
What therapies have you already tried? Please describe what was particularly helpful or unhelpful.
Your answer
If your symptoms were to suddenly disappear, what challenges would you have to be ready to face if any? (Going back to work, dealing with someone or a situation you'd rather not? etc.)
Your answer
What are you able / willing to invest in this treatment in order to get your desired results? (I ask this question so that I can let you know whether I believe we will be able to accomplish effective results for you within your given budget after reviewing your form.)
We will do our best to create breakthroughs as needed during session time. I also find it helpful for my clients to follow up on our progress by doing reading, exercises, meditations, and adjunct therapies I recommend. Is that something you would be willing to do to make the most out of our work together?
Your answer
Please list any concerns, questions or things you would like me to know should we work together.
Your answer
Please complete the captcha before submitting the form.
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms