Intake Form Name * First Name Last Name Email * Phone * (###) ### #### What changes would you like to make in your life over the next few years? * What short-term goals would you like to accomplish over the next few months? * What do you feel may be hindering you the most from making these changes? * How would you rate your current happiness level? * 1 (least happy) 2 3 4 5 (most happy) How would you rate your current stress level? * 1 (least stressed) 2 3 4 5 (most stressed) Who are the most important people in your life? * What do you value most in your life? Do you feel you currently have what you value most? Have you seen a counselor, psychologist, psychiatrist or other mental health professional before? * Yes No Are you currently seeing a counselor, psychologist, psychiatrist or other mental health professional? * Yes No Are you currently taking prescription medication? Yes No Do you use alcohol? No Daily Weekly Rarely Do you use recreational drugs (weed, mushrooms, etc)? No Daily Weekly Rarely Additional comments or concerns: Thank you!