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SE/IFS/Personal Work 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 spiritual life look like when we are done working together?

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

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)?

Please share your current religious/spiritual preference/practice (optional).

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?

IFS Website

SE Website

Social Media

Web search

Referral

Other

Financial commitment

I understand that if I sign up for Personal Work for Helpers there is financial cost involved and I am in a position to make that commitment.

I understand the financial commitment and have the financial resources to make the payments, I understand the financial commitment but would need a sliding scale.