Embodiment of Freedom Intake Form
Please complete and submit this form at least 72 hours before your scheduled appointment time.

The information provided by you will be kept strictly confidential (exceptions to this rule are explained under policies and procedures).
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Full name *
Birth year
Current city and state
Best phone number(s) to reach you
Would you like to subscribe to my newsletter?
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Preferred email address(s)
How did you find Embodiment of Freedom?
Are you currently in a relationship?
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If yes, how long have you been in a relationship?
Type of relationship
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What is the individual's name and age?
Whether single or currently in a relationship, when was your last significant relationship?
What was that individual’s name and current age?
What country or countries are your ancestors from?
If you have children, what are their names, genders, and ages?
Please list any pets that are a part of your family
Please list your brothers’ and sisters’ names and ages
Where do you fall in the birth order?
Are your parents still alive?
Yes
No
Mother
Father
If both parents are alive, are they currently married?
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If they are no longer married, how old were you when your parents separated or divorced?
If one or both of your parents are no longer living, please provide the year in which they passed and the cause of his or her death
How long have you lived in the state you currently live in?
Where did you live before, and how long did you live there?
Please describe your current work or profession
What type of work did you do prior to this profession?
Please list any degrees or vocational trainings you have completed and the fields they are related to
Do you believe in God, Creator, Spirit, the Divine, or Consciousness?
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If yes, list the names you use to refer to Spirit
Do you pray or talk to God/Spirit?
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What current activities help to nourish your spirituality?
Yes
No
Would you like support or guidance in your spiritual life?
Do you spend regular time in nature?
Have you ever learned or practiced meditation?
Do you currently meditate?
Have you participated in any meditation retreats?
Have you ever learned or practiced yoga?
Do you have a yoga practice?
Have you participated in any yoga retreats?
If you have a meditation and/or yoga practice, what is the length and frequency of your practice?
Other than prayer, yoga, or meditation please mention any other spiritually-based practice that you use
Please briefly note here any spiritual experiences and the year in which they occurred (i.e., awakenings, kundalini openings, or near-death experiences)
How is your current general physical health?
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Please briefly note here any current or past physical health concerns
Do you currently use any mood-altering substances (i.e., recreational drugs, caffeine, or alcohol)?
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If yes, please describe the type, quantity and frequency in which they are used
Do you currently take any prescribed medications?
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Do you currently exercise?
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If yes, please list the type, frequency, duration of your workouts
What is your height and current weight range?
Do you feel that you have a healthy relationship with food and your body?
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If no, please briefly comment here (include past or current experience with disordered eating)
Have you had any prior psychotherapy or counseling?
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Please briefly note any current or past mental health concerns
Are you currently seeing a psychotherapist
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What is the name of your therapist?
What year did you begin to see this therapist?
Are you currently working with any alternative health care practitioners (i.e., Naturopath, Acupuncturist, Chiropractor, Herbalist, Massage Therapist or Energy Healer)?
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If yes, please specify:
Please list any emotionally or physically based hospitalizations that you have had (please include the reason for the hospitalization and your age at the time they occurred)
In brief, what issue or situation prompted your call to Elaine, EOF’s spiritual teacher?
Are there additional concerns, issues, or goals you have for your Private Session?
Anything else you would like Elaine to know prior to your appointment?
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