Page 1 of 1

Consultation Intake

Please note: I am not a licensed mental health therapist. I am a therapeutic practitioner, consultant, and educator.

I do not do diagnosis or treatment of mental disorders as defined by the American Psychiatric Association and our work together is not to be used as a substitute for counseling, psychotherapy, psychoanalysis, mental health care, substance abuse treatment, or other professional advice by legal, medical or other qualified professionals and I encourage you to seek such independent professional guidance as needed. I am happy to work alongside your team.

Name

Pronouns

What are your goals for working together? What will your emotional, spiritual, physical, and professional life look like when we are done working together?

What brings you feelings of comfort, safety, and goodness?

What frameworks, theories, and modalities inform your work?

In what ways do you learn what you do not know? How do you explore your blindspots?

Describe your strengths in your practice? What would your clients say you do well?

What in the past has worked well for you when you have wanted to make a shift in your life?

Who are the most important people in your life right now?

Who are part of your support team (friends, therapists, medical professionals, etc)?

How do you spend most of your free time?

Your Email

Your Phone number

Who is your emergency contact (phone, email, address)?

How did you find me?

How did you find me?

Financial commitment

Financial commitment