Client Intake Form (Onboarding)

Welcome. I’m deeply honored you’re here. This form is designed to gently gather helpful information about you, your history, and what brings you to therapy.

Please complete this form honestly and thoroughly. Your responses help ensure that our work together is safe, supportive, and appropriate for your needs. All information is strictly confidential, stored securely, and never shared without your consent (except where required by law).

Warmly,

Monika

Monika Grace, CCTP-II

Integrative Somatic Psychotherapist, Trauma Specialist, EMDR, IFS, SE, PSYCH-K

What is your full name?

Your preferred pronouns

What is your Date of Birth?

What is your mobile? (Country code + mobile / Example: +61470000000)

Which age group best describes you?

Under 18

What is your occupation?

What is your relationship status?

Do you have children?

Emergency contact (Used only in case of crisis or serious concern for your wellbeing)

What is your location?

How did you find out about my work?

What attracted you to my work?

1. Have you ever worked with a therapist, psychologist, psychiatrist, coach, or healer before?

Yes

If yes, briefly describe:

2. Have you ever been diagnosed with any of the following?

Anxiety

Post Traumatic Stress Disorder (PTSD)

Complex Post Traumatic Stress Disorder (C-PTSD)

Dissociative Disorder

Borderline Personality Disorder

Schizophrenia or Psychosis

3. Are you currently under the care of a psychiatrist or mental health provider?

Yes

If yes, please provide details:

4. Are you taking any medications (psychotropic or otherwise)?

Yes

If yes, list medications and purpose:

5. Do you have any medical conditions that may impact your nervous system (e.g., epilepsy, fibromyalgia, migraines, autoimmune disorders)?

Yes

If yes, please explain:

Please note: You do not need to provide detailed or graphic descriptions. We will explore this together in our sessions in a safe way to avoid any dysregulation or retraumatization.

6. Have you experienced any of the following?

Childhood emotional neglect

Physical, sexual, or emotional abuse

Narcissistic abuse or toxic relationships

Loss, grief, or abandonment

Bullying or exclusion

Car accident or injury

Spiritual/ religious trauma

Systemic trauma (racism, oppression, etc.)

Natural Disasters Trauma

If you selected 'Other', please provide more details here:

7. Would you like to share anything about what brings you to therapy at this time?

8. On a scale of 1–10, how would you rate the following (1 = very low, 10 = very high):

Emotional Stability:

Sense of Safety in Your Body:

Connection to Yourself:

Connection to Others:

9. Are you currently experiencing any of the following?

Thoughts of self-harm or suicide

Active addiction or substance misuse

Domestic violence or unsafe living conditions

Narcissistic abusive, Toxic, Coercive or Controlling relationship

Ongoing legal or custody issues

Emotional traumatic flashbacks, Panic attacks, Frequent triggers

Recurring nightmares

If you checked any of the above, please briefly explain (or write "prefer not to say"):

10. What would you like to explore, shift, or heal through this work? (Check all that apply)

Reducing and rewiring anxiety/ Reducing Overthinking

Reducing reactivity and Anger

Nervous system regulation

Healing trauma or PTSD/ CPTSD

Releasing emotional blocks

Helaing from Narcissistic abusive or Coercive controlling relationship

Somatic awareness and embodiment

Processing a specific event or relationship

Improving relationships or boundaries

Increasing self-worth or confidence

Cultivating self-trust, intuition, or inner safety

If you selected other, please add more information here about your goals, needs, desires for transformation:

What is your primary intention or hope for our work together?

Please check each to indicate your agreement:

Untitled checkboxes field

I understand that this work is not a substitute for medical, psychiatric, or crisis care.

I acknowledge that trauma and somatic inner work may bring up strong emotions or physical sensations.

I take full responsibility for my wellbeing during and between sessions.

I understand Monika Grace, CCTP-II Integrative Somatic Psychotherapist is NOT available for emergency, crisis, or after-hours support and I need to seek the appropriate support from the relevant emergency services.

I understand that all information is kept confidential, except where required by law.

I confirm that the information I have provided in this form is true, accurate, and complete to the best of my knowledge. I understand that providing honest responses supports my healing journey, and I offer this information with integrity and self-awareness.