Discovery Session Intake Form

Hello and welcome!

I'm thrilled that we will soon be having our first conversation. But before we do, please fill out this form at least 24-hours prior to our Discovery Session. In addition to the normal contact details, you'll find a few more in-depth questions. These questions will help orient us and allow us to move deeply into at least one area of concern or quandary. Be sure to allow time to fill out these questions, but do not "over think" the answers. Instead, simply go with the most heart-felt and pointed response that emerges in the moment. This not only takes less clock-time but also can be revealing in ways that are surprising and illuminating. If you encounter an error message, it is possible that you did not complete the required fields (those with an *), so please do so and resubmit. Thank you!

Name

First Name

Last Name

Email Address

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth

Gender/ pronouns

In case of emergency, please contact (provide name and phone number).

Have you ever been, or are you currently under the care of a psychologist, psychiatrist, or counselor? If yes, please inform me of the conditions, and/or circumstances surrounding your choosing to receive this form of help and guidance. Include whether or not you are currently taking any medication for psychological purposes.

Partnership Status

Single

Partnered/Married

What is the name of your partner/spouse?

Please provide the names and ages of the important people in your life and their relationship to you.

Is there anything you want me to know about your ethnic identity, cultural heritage, and/or family history?

What is your career, vocation and/or passion? How do you spend the hours of your day?

What are the 3 biggest challenges you are facing at the moment?

If you had a magic wand and could have anything you wanted in regards to these challenges, what would you ask for?

On a scale of 1-10 (10 being the most important), how important is it to transform these challenges?

What do you consider to be your 3 biggest strengths?

How do you experience your spirituality? To what degree is spiritual inquiry and exploration important to you at this time?

Please tell me anything else you wish to before our first conversation. Surprise me!

How did you find out about me? If someone referred you to me, please provide the name of this person so that I can say thank you.