| Life Choices Counseling © |
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| Client Intake Form - Phone for consultation (928) 282-1347 (fax) |
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| Please note: This form may take 15-20 minutes or more to complete. Click here for a printable version; you may wish to review it and then complete the on-line form. |
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Client's name |
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Address |
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City |
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State |
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Zip |
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Phone |
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Email |
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Date of birth |
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Occupation |
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How did you hear about us |
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Reason for requesting our services |
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What previous efforts have you taken to resolve your situation and what were the results? |
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Are you currently under care for any medical treatment for this or any other situation |
Y
N
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Brief description of your situation |
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Have you ever had or are you currently being treated for any of the following (check all that apply) |
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If "other", please expand |
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Are you pregnant |
Y
N
Due date
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Are you currently taking any medications |
Y
N
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If "yes" what and what purpose |
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Do you smoke tobacco? |
Y
N
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Packs per day |
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For how long (years) |
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Do you drink alcohol? |
Y
N
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How much |
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How often |
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Do you have any problems eating or digestive disorders? |
Y
N
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If "yes" please explain |
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How many bowel movements do you have in a day? |
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Do you eat white flour products (bread, crackers, pretzels, pasta, pizza, etc.)? |
Y
N
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Do you drink soft drinks (Pepsi, root beer, etc.)? |
Y
N
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Do you drink coffee or tea? |
Y
N
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If "yes", what kind? |
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Do you eat fast foods (McDonalds, Taco Bell, KFC, etc)? |
Y
N
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Do you eat dairy products |
Y
N
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What type of water do you drink? |
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How many glasses do you drink daily? |
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Are you currently taking any supplements or herbs? |
Y
N
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If "yes", please explain |
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Have you ever done any type of body cleansing? |
Y
N
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If "yes", please explain |
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Do you practice any form of relaxation or meditative techniques? |
Y
N
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If "yes", please explain method and how long |
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Do you sleep soundly? |
Y
N
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Do you take time for self improvement? |
Y
N
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List examples |
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| Do you have fears or phobias? |
Y
N
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If "yes", please explain |
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Do you have issues with any of the following (fill in the number that applies to you) 1=mild, 2=moderate, 3=severe. |
Parents |
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Singleness |
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Marriage |
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Children |
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In-Laws |
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Divorce/Separation |
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Child Custody |
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Loneliness |
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Anger Control |
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Mood Swings |
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Fear/Anxiety |
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Communication |
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Procrastination |
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Self-Esteem |
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Confidence |
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Past Hurts |
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Grief/loss |
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Depression |
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Stress Management |
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God/Faith |
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Co-dependency |
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Letting go |
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Aging/dependency |
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Disabled |
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Work/career |
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School/learning |
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Money/budgeting |
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Weight control |
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Alcohol/drugs |
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Other addictions (please specify) |
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Do you have any behavior patterns that you wish to change? |
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If "yes" please explain |
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What do you expect from these sessions? |
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Do you have any questions about or for Life Choices Counseling©? |
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"You have the right and responsibility to explore and educate yourself about how your body and mind functions and its needs for creating optimal health. Life Choices Counseling© is not intended to replace medical treatment or psychiatric help.
It is your responsibility to seek appropriate medical and mental health intervention. If you are currently taking pharmaceutical drugs, please talk with your healthcare professional about negative effects that your drugs can have on herbal remedies, nutritional supplements and food.
It is Kimberly Miles' intent to educate you in nutrition and techniques that may result in achieving optimal physical, mental, and emotional health. Kimberly Miles and Life Choices Counseling© shall have neither liability nor responsibility to any person or entity with respect to any damage, loss, consequences or injury related to information given, including recommended products and services.
I acknowledge understanding all the questions and information. I have answered all questions completely and accurately to the best of my knowledge. I am fully aware that the success of my program depends upon taking responsibility for myself."
I understand and accept
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