NEW CLIENT INFORMATION FORM
Acorn Healing Arts, LLC, Mori Montagne, BSN,MN, EFT-ADV, Life Mastery Coach
Please provide the following information and answer the questions below.
Today's Date: _______________ Age: _____
Name: _________________________________________________ Best Phone number to call: _________________Best time to call?_____________________ Is it okay to text? □ Yes □ No Is it okay to leave a detailed message at this number? □ 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: ___________________________________________________________________ For appointment scheduling, what are the best: Times of day:______________________ , Days of the week:____________________________
Gender identification and preferred pronouns:_____________________________________________________ Current relationship Status (optional):__________________________________________________________
Emergency Contact Information:Name: ______________________________________________Relationship: ______________________ Phone: ______________________________________________
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 any physical health concerns or phobias that you wish to address? Briefly describe--we will address in more depth at your first appointment:________________________________________________________ _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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? □ Yes □ No Are you currently seeing a therapist? □ Yes □ No If yes, please briefly describe what issues you are addressing in therapy: ________________________________________________________________________ _________________________________________________________________________________________________________________________
Are you currently taking any medications? □ Yes □ No If yes, please list: _______________________________________________________________________ ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Other helpful stuff...optional: Do you have anything else you wish to share that you feel is important or you wish to address regarding your upcoming appointment? ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Please list the first name (or initial) and relationship of the five most important people in your life: (optional) 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?_________________________________________________________________________________
Copy and paste this form into link below, which is a secure and protected link. Fill out information before sending please. Your typed name in this format is considered a legal signature. If you prefer you can print and bring with you if we are seeing each other in person.