SecureSelf Intake Form Copy

Name

First

Last

Date Of Birth

Are you married/partnered? *

How long married/partnered?

Please describe your family and important relationships for you within the family. (children, stepchildren, grandchildren, parents, caregivers – age, sex)

I work deeply with intentions. Your intentions are about what you want for your life right now or in the future. This might be a changing/growing experience as you evolve, redefining your intention. What are your intentions for this session?

Do you consider yourself a highly sensitive person? *

What growing edges are you working with in your current life? What aspect of your early and/or present life would you like to explore during this session?

What are your current resources or self care practices? What helps you when you feel triggered or overwhelmed?

Meditation
Massage
Baths
Talking With Friends/Partner
Eating Well
Listening To Wise Teachings
Exercise
Yoga

Please explain other ways you take care of yourself, self care practices.

It's very important to note that recreational drugs and alcohol can impair our work together in a big way. In order to work together it's important that you are recreational drug free for two weeks before the session. Please be free of alcohol for 48 hours. I typically don't work with clients who are using recreational drugs on a regular basis, or who have an active addiction to opioids or alcohol, because of the nature and integrity of our work together

Are you presently using any recreational drugs, alcohol or nicotine, THC? (amount per day / week) *

Amount per day/week, please describe

How is your health/sleep?

Do you currently have on-going support for yourself, such as coaches or therapists? It’s often great to have many layers of support. Please explain if you have these resources

List other physicians or health care practitioners you are being treated by.

If you are a mother or parent and you have experienced birth trauma during the birth of your child please share about your experience, and what you perceive about your child's birth experience.

If you experienced birth trauma when you were born, please share about what you have learned about this moment, from information told to you by your family members, or what you have learned from your own intuition about your birth

Please check what you know or think applies to your birth history. My birth was:

An unmedicated vaginal birth in a hospital
An unmedicated vaginal birth at home
An anesthesia birth
With forceps
With cranial suction
With fetal heart monitor
C-section
Breech
A multiple birth

If there were other birth complications, please explain.

Please check what you know or think applies to your prenatal and birth history.

I had a twin that died as a stillbirth.
I had a twin that died in the womb.
My mother experienced a significant loss (death of a loved one or other trauma while she was pregnant with me)

Please describe detail about the above checked choices.

If you were premature, how many weeks? (number)

I was in a Neonatal Intensive Care Unit. Please state how long?

I was incubated. How long?

Where was your father during your birth?

Where you separated from your mother at birth, sent to a nursery? *

Yes
No
I don't know

Please explain with all the details you know.

Were you breastfed? *

Yes
No
I don't know

How long?

Men, were you circumcised as an infant? *

Please note any interventions shortly after birth such as hospitalization for illness or high jaundice, operations, illnesses as an infant or a child.

Did either or both of your parents lose another child to miscarriage, abortion, stillbirth, or childhood death? *

If yes, are you aware of how this affected you? Give dates and circumstances.

Who raised you? Were your parents your biological parents? Were you raised by a single parent? If your parents split up, how old were you? Did you have other major primary caregivers like grandparents, aunt and uncles, guardians or adoptive parents?

Do you or did you have siblings? *

If yes, indicate ages relative to you, nature of relationship as children.

Please relate any other information you know concerning your conception, your parents’ attitude toward having you (planned, unplanned, wanted, confused, unwanted). If unwanted, did they consider or attempt abortion?

What do you know about your life in the womb including physical effects (maternal or paternal smoking, drinking, drugs, mom’s diet), and emotional effects including absence or presence of father during pregnancy or birth, parents’ relationship with each other during your pregnancy,

What were your siblings’ attitudes toward your birth. If you are adopted, give information about transition in hospital and new family as well as any birth history known.

Have you ever lost a child to miscarriage, abortion, stillbirth or death? *

If yes, please explain circumstances and dates and how this affects you today.

Have you ever been or are you in an abusive relationship now? *

If yes, please state when, what relation the person was or is to you, whether the abuse was or is physical, sexual and or emotional. If a past relationship, what action did you take? If present, what are you doing about it? Please give details

Have you ever been prescribed medications for mental health reasons? *

If yes, please describe the circumstances and outcomes with dates.

Have you ever been hospitalized for mental health reasons? *

If yes, please describe the circumstances and outcomes with dates.

Have you ever contemplated or attempted suicide? *

If yes, please describe the circumstances with dates. And please explain if you are still in contact with your support team of therapists regarding this?

I agree to the following that apply to your session. Please initial each and sign at the bottom.

Taking responsibility for my well-being during and after the session.

Abstaining from alcohol and recreational drugs 72 hours before session.

I am a highly sensitive person and I cannot tolerate being around mobile phones or other wifi or bluetooth enabled transmitting devices. *

I understand your sensitivities as explained above. If meeting in person, I will keep phones and other transmitting devices on airplane mode during our session. If this is a problem because of family or children or other circumstances, please let me know more information so we can find a win-win. Checking this box means that you agree, but if a discussion is needed please fill in some more information below. (I will remind you about this before we meet in person.)

I would like to discuss possibilities of having access to my cell phone during our in person session. The following is my circumstance:

If meeting in person, because of my sensitivities I am unable to offer support to anyone that smokes cigarettes. Please check this box to verify you do not smoke if meeting in person.

If meeting in person, I request that you not wear strong-scented perfume, and do not use strong-scented laundry detergent or strong-scented personal care products. Please check this box to verify.

Date :

Connect With Derek