Today’s Date: Click here to enter a date.
Please download this form and enable editing(it can’t be filled online without downloading and enabling first!), complete it, print it, sign the last page, and bring it to your first appointment. Provide as much information as you feel comfortable.
General InformationName: Click here to enter text. / Age: / Birthdate: Click here to enter text.
Street Address: Click here to enter text. / City: Click here to enter text. / Zip: Click here to enter text.
Phone: Click here to enter text. / OK to leave detailed voicemail message? Yes ☐ No ☐ / Email: Click here to enter text.
Occupation:Click here to enter text. / Relationship status:Choose an item. / Race/Ethnicity: Click here to enter text.
Gender Identification: Choose an item. / Sexual Orientation:Choose an item. / Religious Affiliation: Click here to enter text.
# of Children: Click here to enter text. / Ages of Children: Click here to enter text. / Spiritual Practice: Click here to enter text.
I live with: Click here to enter text. / How did you hear about Sound Mindfulness Group? Choose an item. / Name of person who referred you: Click here to enter text.
Emergency Contact (name, relationship, phone number): Click here to enter text.
Starting Therapy
What brings you to therapy at this point in your life?Click here to enter text.
Describe what you hope to accomplish in therapy:Click here to enter text.
Are you interested in exploring nutritional strategies to support your mental health? Yes ☐ No ☐ Not Sure/Maybe ☐
Therapy HistoryHave you been in counseling for this or other concerns in the past? Yes ☐ No ☐
If yes, briefly describe: Click here to enter text.
Family DetailsNumber of siblings in your family: Click here to enter text.
What number are you in the birth order of your siblings? Click here to enter text.
Current relationship status of your parents:Choose an item.
If parents divorced, split up, or separated, at what age were you when this happened? Click here to enter text.
Were you adopted? Yes ☐ No ☐ If yes, at what age and under what circumstances? Click here to enter text.
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:Click here to enter text.
Personal/Family Medical and Mental Health Historyme past / me current / family members / me past / me current / family members / me past / me current / family members
Allergies / ☐ / ☐ / ☐ / Fibromyalgia / ☐ / ☐ / ☐ / Anemia / ☐ / ☐ / ☐ /
Asthma / ☐ / ☐ / ☐ / High Blood Pressure / ☐ / ☐ / ☐ / ADHD / ☐ / ☐ / ☐ /
Eczema / ☐ / ☐ / ☐ / Irritable Bowel Syndrome / ☐ / ☐ / ☐ / Crohn’s Disease / ☐ / ☐ / ☐ /
Migraine / ☐ / ☐ / ☐ / Osteoporosis / ☐ / ☐ / ☐ / Cancer / ☐ / ☐ / ☐ /
Diabetes / ☐ / ☐ / ☐ / High Cholesterol / ☐ / ☐ / ☐ / Arthritis / ☐ / ☐ / ☐ /
Stroke / ☐ / ☐ / ☐ / Learning Disability / ☐ / ☐ / ☐ / Heart Disease / ☐ / ☐ / ☐ /
Sexual Problems / ☐ / ☐ / ☐ / Thyroid Disease / ☐ / ☐ / ☐ / Eating Disorder / ☐ / ☐ / ☐ /
Anxiety / ☐ / ☐ / ☐ / Depression / ☐ / ☐ / ☐ / Phobias / ☐ / ☐ / ☐ /
Bipolar / ☐ / ☐ / ☐ / Panic Attacks / ☐ / ☐ / ☐ / Suicidal / ☐ / ☐ / ☐ /
Self-Harm / ☐ / ☐ / ☐ / Borderline Personality Disorder / ☐ / ☐ / ☐ / Obsessive/ Compulsive (OCD) / ☐ / ☐ / ☐ /
Other conditions not listed above: Click here to enter text.
Approx. date of last physical exam: Click here to enter text. Approx. date of last bloodwork: Click here to enter text.
Areas that were of concern at your last exam: Click here to enter text.
Did your practitioner recommend any treatments? Yes ☐ No ☐ If yes, describe and explain whether you have implemented recommendations: Click here to enter text.
Current prescription medications:Click here to enter text.
Current supplements taken:Click here to enter text.
Digestion and Nutrition
yes / no / yes / noConstipation / ☐ / ☐ / Diarrhea / ☐ / ☐ / Frequency of bowel movements per day: Click here to enter text.
Diarrhea / ☐ / ☐ / Nausea / ☐ / ☐ / Consistency: Choose an item.
Acid Reflux / ☐ / ☐ / Bloating / ☐ / ☐ / Describe food allergies or sensitivities: Click here to enter text.
Dietary choices/restrictions (e.g., Vegan, Gluten-Free, Dairy-Free)? Yes ☐ No☐If yes, describe:Click here to enter text.
Do you experience cravings? Yes ☐ No ☐ If yes, describe: Click here to enter text.
Typical breakfast: Click here to enter text.
Typical lunch: Click here to enter text.
Typical dinner: Click here to enter text.
Typical snacks: Click here to enter text.
LifestyleScreen Time
Number of hours of screen time per day (phone + computer + video games + TV)?Click here to enter text.
Do you find it hard/impossible to be away from your devices? Yes ☐ No ☐ Unsure ☐
Substance Use Currently or In Past
Regarding Current Use / Regarding Past UseI currently use / my use is interfering with my life / I feel the need to cut down on use / my use interfered with my life in the past / I felt the need to cut down on my use in the past
Tobacco / ☐ / ☐ / ☐ / ☐ / ☐ /
Alcohol / ☐ / ☐ / ☐ / ☐ / ☐ /
Recreational Drugs / ☐ / ☐ / ☐ / ☐ / ☐ /
Caffeine / ☐ / ☐ / ☐ / ☐ / ☐ /
Sugar / ☐ / ☐ / ☐ / ☐ / ☐ /
Sleep
Hours of sleep on average per night:Click here to enter text.
Quality of sleep:Choose an item.
How you awake: Choose an item.
Do you struggle with insomnia? Yes ☐ No ☐ If yes, what methods have you tried to address your difficulty sleeping and are they working?Click here to enter text.
Physical Activity and Energy Level
What do you do for physical activity and with what frequency?Click here to enter text.
On a scale of 0 to 10, what is your current energy level (0=completely drained; 10= very energetic)?Click here to enter text.
Stress
On a scale of 0 to 10, what is your current overall stress level (0 = none; 10= stressed to the max)? Click here to enter text.
Biggest sources of stress in life currently: Click here to enter text.
How do symptoms of stress show up in your body?Click here to enter text.
How do you typically cope with stress?Click here to enter text.
Relaxation, Joy, and Support
What activities recharge your batteries?Click here to enter text.
What/who are the biggest sources of joy in your life? Click here to enter text.
Who do you rely on for emotional support in your life?Click here to enter text.
Adverse Events in ChildhoodWhile I was growing up, during my first 18 years of life…. / Yes / No / If yes, how much did this experience bother you at the time? / If yes, how much does this bother you now?
0=not at all to 5= very much / 0=not at all to 5= very much
I experienced physical abuse (e.g., pushed, grabbed, slapped, beaten, or harshly punished) from a parent or other person. / ☐ / ☐ / Choose an item. / Choose an item. /
I experienced sexual abuse (e.g., touching, molesting, fondling, or intercourse) from a parent or other person. / ☐ / ☐ / Choose an item. / Choose an item. /
I experienced emotional abuse (e.g., humiliation, threats, boundary violations, blame, bullying) from a parent or other person. / ☐ / ☐ / Choose an item. / Choose an item. /
I experienced neglect (e.g., real or threatened abandonment, failure to provide essentials) from a parent. / ☐ / ☐ / Choose an item. / Choose an item. /
I witnessed family members suffering from physical, sexual, or emotional abuse. / ☐ / ☐ / Choose an item. / Choose an item. /
My parents separated or divorced. / ☐ / ☐ / Choose an item. / Choose an item. /
A parent, sibling, or other important person in my life died. / ☐ / ☐ / Choose an item. / Choose an item. /
A parent or other adult in my home was an alcoholic or drug addict. / ☐ / ☐ / Choose an item. / Choose an item. /
A parent or other adult in my home was depressed, mentally ill, or suicidal. / ☐ / ☐ / Choose an item. / Choose an item. /
I experienced discrimination because of my race, gender, appearance, sexual orientation, religion, or other factors. / ☐ / ☐ / Choose an item. / Choose an item. /
Other childhood difficulties that are not captured above:Click here to enter text.
Adverse Events in Adulthood
Have you faced significant challenges as an adult (e.g., serious illnesses, accidents, losses, adult trauma, abusive or unstable relationships)? Yes ☐ No ☐ If yes, briefly describe: Click here to enter text.
Did We Miss Anything?Is there any other information you would like us to know about you at this time that isn’t captured above?
Yes ☐ No ☐ If yes, please describeClick here to enter text.
Disclosure Form, HIPAA Privacy Notice, and Agreementsclick if you agree
I have read the Disclosure Statement available online at SoundMindfulnessGroup.com that describes provider backgrounds, therapy modalities used, fees, policies, and procedures. / ☐ /
I have read the HIPAA Notice of Privacy Practices available online at SoundMindfulnessGroup.com that describes how my personal health information may be used. / ☐ /
I understand that whatever I discuss with my provider is confidential; however my provider is required by law to release confidential information if he or she become aware that: 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 information to a lawyer or judge. / ☐ /
If I am unable to keep an appointment, I will notify youat least 24 hours in advance. I understand that 1) 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 and 2) my insurance cannot be billed and will not cover missed appointments. / ☐ /
I understand that I am responsible for payment of any fees not covered by my insurance policy. / ☐ /
I will letmy provider know at least 2 sessions in advance if I wish to end therapy. This gives us time to process our relationship, summarize and celebrate your progress, and say goodbye to one another. / ☐ /
I would like to be added to Sound Mindfulness Group’s mailing list to receive periodic emailed updates, class registration alerts, and newsletters (your email address will not be shared with others and you may opt out at any time). / ☐ /
I agree to participate in services with Sound Mindfulness Group. 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 treatment and the right to choose a practitioner and treatment modality that best suits my needs. I have read the above informed consent, understand, and agree to it.
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