New Client Intake form

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NEW CLIENT INFORMATION FORM

Acorn Healing Arts, LLC, Mori Montagne, BSN,MN, EFT-ADV

Please provide the following information and answer the questions below.

Client Information
Date: _______________
Name: _________________________________________________
Best Phone number to call: ______________________
Best time to call?_____________________
Is it okay to leave messages at this number? □ Yes □ No  Is it okay to text? □ Yes   □ No

E-Mail Address (if you have one): ____________________________________________________________________
Mailing address (optional):_____________________________________________________________
________________________________________________________________________________
How long have you been living at this address? _________How many times have you moved in past 3 years?____
Occupation: ______________________________________
Date of Birth: ________________ (or age if you prefer not to share your date of birth)

For appointment scheduling, what are the best:
Times of day:________________________
Days of the week:_____________________

Gender identification and preferred pronouns::_______________________________________________

Relationship Status: (optional)

Current relationship status:_____________________________________________________________ 

Emergency Contact Information:
Name: ______________________________________________
Relationship: _________________________________________
Phone: ______________________________________________

General Health:

How would you rate your overall physical health? □ Excellent □ Great □ Good □ Fair □ Poor
Do you have any sleep problems? □ Yes □ No
If yes, please describe:_____________________________________________________
Are you dealing with any past or current addictions? □ Yes □ No
If yes, please describe: ____________________________________________________ 

Do you have any significant past or recent/current traumas, physical emotional or psychological that you are comfortable sharing or wish to address?___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Have you had any issues with Depression, Anxiety, or ADD/ADHD (Attention Deficit Disorder/Attention Deficit Hyperactivity Disorder)? □ Yes □ No                                                                                                                                                    If yes, please describe:_____________________________________________________

Do you have any suicidal or otherwise harmful thoughts or intentions?_______________________________________________________________________________

Are you currently seeing a therapist? □ Yes □ No
If yes, please describe what issues you are addressing in therapy:
_________________________________________________________________________________
_________________________________________________________________________________
Are you currently taking any medications? □ Yes □ No
If yes, please list: _____________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

Other helpful stuff...optional: 

Please list the first names and relationships of the five most important people in your life: 1. _____________________________________________________________________ 2. _____________________________________________________________________ 3. _____________________________________________________________________ 4. _____________________________________________________________________ 5. _____________________________________________________________________

Do you have pets? □ Yes □ No If yes, please list: _________________________________________________________ Education: ______________________________________________________________

Are you usually: □ Early □ On Time □ Running Late
Do you exercise regularly? □ Yes □ No
If yes, please describe what you do and how often:_______________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
How often are you on electronic devices (computer, phone, TV, social media, gaming platforms)
_________________________________________________________________________________
What are your favorite hobbies and sports?
_________________________________________________________________________________
_________________________________________________________________________________
What do you do for fun?
_________________________________________________________________________________
_________________________________________________________________________________
Do you have a religious or spiritual orientation?
_________________________________________________________________________________
_________________________________________________________________________________
When you treat yourself, what are things you like to do?
_________________________________________________________________________________
_________________________________________________________________________________
What is your idea of a perfect vacation/ or where are your "Zen spaces" and happy places?
_________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________

How did you hear about me?
_________________________________________________________________________________


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