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Interconnected Counseling
Intake Form
In order to focus our sessions on the most important topics, it's helpful to have some background information about you, as well as contact information.
All of this information will be considered confidential and not shared with others without your express permission. See the
Interconnected Counseling Confidentiality Agreement
.
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Email
*
Your email
Your name or nickname:
*
Your answer
Your phone number:
*
Your answer
What is a typical day look like for you? Start in the morning and describe your habits, work hours, etc.
Your answer
How many hours do you sleep on a typical night?
Is there anything else I should know about the quality of your sleep?
Your answer
Do you exercise? How often, and for how long?
What is an enjoyable or motivating form of exercise for you? (Swimming, running, etc.)
Your answer
What does your diet look like? What kinds of foods & drinks do you consume on a typical day?
Your answer
Is there anything else I should know about your health or medical history?
Your answer
Thank you for providing this information. Do you have any questions for me?
Your answer
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