Shamanic Intake Form
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Email *
First name:  *
Last name:  *
Are you currently receiving psychological services, professional counseling, psychiatric services, or any other mental health services?   *

Are you currently taking any psychiatric prescription medication? 

*

If yes, please list:

Have you been prescribed psychiatric prescription medication in the past? 

 *

If yes, please list:

Have you been psychiatrically hospitalized in the past?

 *
 If yes, please list dates below:
How would you rate your physical health at the present time?   *
Are you on any medication for physical/medical issues? *
If yes, please list:
Are you having any problems with your sleep habits? *
If yes, check those that apply

Do you consume alcohol regularly?  

*
In one month, how many times do you have four or more drinks in a 24-hour period?  
How often do you engage in recreational drug use?     *
What kinds of recreational drugs do you use: 
Are you currently in a romantic relationship? *

If yes, how long have you been in this relationship?

On a scale from 1-10 (10 being great), how would you rate the quality of your relationship?  

 *

In the last year, have you had any major life changes (e.g. new job, moving, illness, relationship change, etc.)? 

 *
Do you practice a religion?  *
If yes, what is your faith? 
Are you currently employed? *
If yes, who is your employer?
What is your position?

Are you happy in your current position?

Clear selection

Does your work make you stressed?

Clear selection

If yes, what are your work-related stressors?

Have you felt depressed recently?  

*

If yes, for how long?

Have you had any suicidal thoughts recently?     

*

If yes, how often?

Clear selection

Have you ever had suicidal thoughts in your past? 

*

If yes, how long ago?

How often did you have these thoughts? *
Check any of the below that apply to you. Please  check past or current. 
Past
Current
Depressed mood
Mood Swings
Excessive Worry
Suicidal Thoughts
Memory Lapse
Anxiety
Sleep Disturbance
Time loss
Panic Attacks
Phobias
Traumatic Event(s)
Body Complaints
Relationship Problems
Hallucinations
Eating difficulties
Alcohol/Drug abuse
Clear selection

The following is to provide information about your family history. Please mark each as yes or no.

Depression  

 *

If yes, please indicate the family member(s) affected.

Suicide  *

If yes, please indicate the family member(s) affected.

Anxiety Disorders *

If yes, please indicate the family member(s) affected.

Bipolar Disorder *

If yes, please indicate the family member(s) affected.

Panic Attacks  *

If yes, please indicate the family member(s) affected.

Alcohol/Substance Abuse *

If yes, please indicate the family member(s) affected.

Eating Disorder *

If yes, please indicate the family member(s) affected.

Trauma History *

If yes, please indicate the family member(s) affected.

Domestic Violence  *
If yes, please indicate the family member(s) affected.

Sexual Abuse

 *
If yes, please indicate the family member(s) affected.
Obsessive Compulsive Behavior
 *
If yes, please indicate the family member(s) affected.
Schizophrenia *
If yes, please indicate the family member(s) affected.

List your strengths and what you like most about yourself:

 *

List areas you feel you need to develop: 

 *

What are some ways you cope with life obstacles and stress?

 *

What are your goals for our session(s)/what would you like to accomplish? 

 *
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