Intake for Therapy – Carrie Ishee

Intake for Therapy | Section #1

Step 1

The following items constitute some preliminary information that will assist me in understanding you and your needs. Please send your responses by e-mail to me at carrie@carrieishee.com Take as much space as you need; don’t restrict yourself to the space available on this sheet. If you prefer not to respond to any of the items, leave them out. If applicable, we can explore those items at a later date.

All personal information is confidential and is treated appropriately.

Name

Home Address

Occupation

Date of Birth

Phone

Fax Number

Email Address

Referred By

Key people in your life

Intake for Therapy | Section #2

Step 1

We following questions will allow me to get to know you better as we begin our work together.

1) As you contemplate doing healing work what is it that you want to focus on?

2) As you achieve those results, how will your life feel different from the present?

3) What habits / activities / thought processes do you believe need to be dropped, simplified or let go of, in order to achieve those results?

4) List five (5) of your personal strengths or assets.

5) List five (5) energy drains that exist in your life at present.

6) List at least five (5) empowering habits that you currently or desire to practice (indicate (C) current / (D) desired) (e.g. exercise three tmes weekly (C); daily meditation practice (D)).

7) Describe your childhood (in a few paragraphs). Name the wounds that you experienced that are now being activated by the current challenges in your life.

8) Sometimes people have experienced other traumatic events at other times in their lives. Has this happened in your life? Have you ever experienced, or witnessed, or been confronted with other traumatic events?

9) What are the symptoms of trauma you are now experiencing? (examples: numbing, dissociation, depression, hyper-vigilance, intrusive memories, inability to trust people (not just your partner), fear of open spaces, insomnia, etc…

10) Have you ever had any impulses to harm yourself? Any suicidal thoughts or episodes?

11) Are you currently on medication? For what?

12) Please share any relevant medical history including any medical traumas that you have experienced in your life that may be impacting your current life.

13) Are you currently using any mind-altering drugs including alcohol? If yes, what is your daily usage?

14) What is your chosen spiritual path? How has this changed as a result of the trauma?

15) What makes you feel most alive?

16) When do you experience your creativity?

17) Describe your relationship to art, creativity, and image making.

18) What hopes and dreams do you need to re-engage as part of your healing?

Please use this area to share with me anything else you want me to know:

Step 2

Next: Client Information Form

Intake for Therapy | Section #1

Step 1

Intake for Therapy | Section #2

Step 1

Step 2

Join the Waitlist

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