✧ Client Intake Reflection

(This form is both informational and intentional — designed to help you begin integrating before we even meet.)

 

Personal Information
 

Full Name:
 

Date of Birth:
 

Phone:
 

Email:
 

Emergency Contact:

 

Current Support 
 

Are you currently under the care of a physician?
 

 

Are you currently seeing a therapist or psychiatrist?
 

 

Are you taking medications that influence mood, sleep, or cognition?

 

 

Your Intention
 

What brings you into this season of work?

 

 

What feels ready to shift?

 

I

f we were successful together, how would your inner world feel different?

 

 

What would your strongest, most aligned self look like?
 

 

Self-Assessment
 

On a scale of 1-10, how comitted are you to this process?

 

 

 

What patterns tend to pull you off course?

 

What strengths have helped you before?