Client Intake - Jennifer McKeever

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From Trauma to Trust
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Meet Jennifer
Offerings
From Trauma to Trust
Resources
Contact

Client Intake Form

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Name*
First Last
Gender
Date of Birth*

Year
Month
Day
Email*
Enter Email Confirm Email
Phone*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Starting Sessions
What are the central issues in your life at this time?
Describe what you hope to accomplish in our work together:
Therapy History
Have you been in counselling for this or other concerns in the past?
- yes
- no
Please describe briefly about the counselling.

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Family Details
Were you adopted?
- yes
- no
At what age were you adopted and under what circumstances?
As far as you know, did your mother or you experience difficulties during her pregnancy, labor, or shortly after your birth?
- yes
- no
If yes, please explain
If your parents divorced, split up, or separated, at what age were you when this happened?
Personal Medical and Mental Health History
Allergies
- me past
- me current
Asthma
- me past
- me current
Eczema
- me past
- me current
Migraine
- me past
- me current
Pregnancy
- me past
- me current
Stroke
- me past
- me current
Sexual Problems
- me past
- me current
Anxiety
- me past
- me current
Bipolar
- me past
- me current
Self-Harm
- me past
- me current
Fibromyalgia
- me past
- me current
High Blood Pressure
- me past
- me current
Irritable Bowel Syndrome
- me past
- me current
Osteoporosis
- me past
- me current
Epilepsy or seizures
- me past
- me current
Learning Disability
- me past
- me current
Thyroid Disease
- me past
- me current
Depression
- me past
- me current
Panic Attacks
- me past
- me current
Borderline Personality Disorder
- me past
- me current
Glaucoma
- me past
- me current
ADHD
- me past
- me current
Crohn’s Disease
- me past
- me current
Cancer
- me past
- me current
Arthritis
- me past
- me current
Heart Disease
- me past
- me current
Eating Disorder
- me past
- me current
Phobias
- me past
- me current
Suicidal
- me past
- me current
Obsessive/ Compulsive (OCD)
- me past
- me current
Other conditions not listed above:
Did you have any surgeries in the past?
- yes
- no
Please list any surgeries you’ve had and their dates:
Are you currently taking any prescription medications?
- yes
- no
Please list the prescription medications:
Are you currently taking any supplements?
- yes
- no
Please list the supplements:

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Personal Medical and Mental Health History
Screen time
Number of hours of screen time per day (phone + computer + video games + TV)
Substance Use Currently or In Past
Tobacco
Please choose all relevant options!
- I currently use it.
- I quit using it.
- I used it in the past.
- I have never used it.
Current use of tobacco
- My use is interfering with my life.
- I feel the need to cut down on use.
Past use of tobacco
- My use interfered with my life in the past.
- I felt the need to cut down on my use in the past.
Alcohol
Please choose all relevant options!
- I currently use it.
- I quit using it.
- I used it in the past.
- I have never used it.
Current use of alcohol
- My use is interfering with my life.
- I feel the need to cut down on use.
Past use of alcohol
- My use interfered with my life in the past.
- I felt the need to cut down on my use in the past.
Recreational Drugs
Please choose all relevant options!
- I currently use them.
- I quit using them.
- I used them in the past.
- I have never used them.
Current use of recreational drugs
- My use is interfering with my life.
- I feel the need to cut down on use.
Past use of recreational drugs
- My use interfered with my life in the past.
- I felt the need to cut down on my use in the past.
Sleep
Hours of sleep in average per night:
Quality of sleep
Do you struggle with insomnia?
- yes
- no
If yes, what methods have you tried to address your difficulty sleeping and are they working?
Physical Activity and Energy Level
What do you do for physical activity and with what frequency?
On a scale of 0 to 10, what is your current energy level (0 = completely drained; 10 = very energetic)?
Stress
On a scale of 0 to 10, what is your current overall stress level (0 = none; 10 = stressed to the max)?
Biggest sources of stress in life currently:
How do symptoms of stress show up in your body?
How do you typically cope with stress?
Relaxation, Joy, and Support
What activities recharge your batteries?
What/who are the biggest sources of joy in your life?
Who do you rely on for emotional support in your life?

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Adverse Events in Childhood
While I was growing up, during my first 18 years of life….
I experienced physical abuse (e.g., pushed, grabbed, slapped, beaten, or harshly punished) from a parent or other person.
- yes
- no
How much did this experience bother you at the time?
0 = not at all to 5 = very much
How much does this bother you now?
0 = not at all to 5 = very much
I experienced sexual abuse (e.g., touching, molesting, fondling, or intercourse) from a parent or other person.
- yes
- no
How much did this experience bother you at the time?
0 = not at all to 5 = very much
How much does this bother you now?
0 = not at all to 5 = very much
I experienced emotional abuse (e.g., humiliation, threats, boundary violations, blame, bullying) from a parent or other person.
- yes
- no
How much did this experience bother you at the time?
0 = not at all to 5 = very much
How much does this bother you now?
0 = not at all to 5 = very much
I experienced neglect (e.g., real or threatened abandonment, failure to provide essentials) from a parent.
- yes
- no
How much did this experience bother you at the time?
0 = not at all to 5 = very much
How much does this bother you now?
0 = not at all to 5 = very much
I witnessed family members suffering from physical, sexual, or emotional abuse.
- yes
- no
How much did this experience bother you at the time?
0 = not at all to 5 = very much
How much does this bother you now?
0 = not at all to 5 = very much
My parents separated or divorced.
- yes
- no
How much did this experience bother you at the time?
0 = not at all to 5 = very much
How much does this bother you now?
0 = not at all to 5 = very much
A parent, sibling, or other important person in my life died.
- yes
- no
How much did this experience bother you at the time?
0 = not at all to 5 = very much
How much does this bother you now?
0 = not at all to 5 = very much
A parent or other adult in my home was an alcoholic or drug addict.
- yes
- no
How much did this experience bother you at the time?
0 = not at all to 5 = very much
How much does this bother you now?
0 = not at all to 5 = very much
A parent or other adult in my home was depressed, mentally ill, or suicidal.
- yes
- no
How much did this experience bother you at the time?
0 = not at all to 5 = very much
How much does this bother you now?
0 = not at all to 5 = very much
I experienced discrimination because of my race, gender, appearance, sexual orientation, religion, or other factors.
- yes
- no
How much did this experience bother you at the time?
0 = not at all to 5 = very much
How much does this bother you now?
0 = not at all to 5 = very much
Other childhood difficulties that are not captured above:

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Adverse Events in Adulthood
Have you faced significant challenges as an adult (e.g., serious illnesses, accidents, losses, adult trauma, abusive or un-stable relationships)?
- yes
- no
If yes, briefly describe:
Did I miss anything?
Is there any other information you would like me to know about you at this time that isn’t captured above?
- yes
- no
If yes, briefly describe:
Disclosure Form and Agreements
I understand during counselling sessions touch may be used to help facilitate greater body awareness, support the development of emotional resources and release of traumatic stress. I can refuse touch at any time.
- yes
I understand that whatever I discuss is confidential; however it is required by law to release confidential information if: 1) a child or vulnerable adult is experiencing physical abuse, sexual abuse, or neglect, 2) I intend to harm myself or others, 3) a court order has been issued requiring release of confidential infor-mation to a lawyer or judge.
- yes
If I am unable to keep an appointment, I will notify Jennifer at least 24 hours in advance. I understand that I will be charged a regular full session fee for scheduled sessions if I don’t show up for or call/email to cancel with appropriate notice.
- yes
I have read the above information and have had an opportunity to ask questions to clarify my understanding of the information. I understand that I have the right to refuse or terminate sessions at all times, or to refuse touch, Somatic Experiencing® techniques, or any other intervention proposed. I have read the above informed consent, understand, and agree to it.*
- yes

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Trauma is what happens to you.
Healing is what happens through you.

This is the journey from trauma to trust.

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