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Confidential Intake Form
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* Indicates required question
First and Last Name
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Your answer
Preferred name
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Your answer
Gender Identification and pronouns
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Your answer
Email Address
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Your answer
Phone number at which Amma or Transcendental Service, LLC can contact you or leave a message. The caller will not identify themself or state why they are calling, if someone other than yourself answers.
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Your answer
Street Address, City, State, and Country
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Your answer
Birthdate
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MM
/
DD
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YYYY
Relationship Status
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Your answer
Emergency Contact: Name, Phone Number, and Relation to You
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Your answer
GP or PCP who is currently treating you: Name and Phone Number
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Your answer
Do you have any current or significant past medical complaints/problems? If yes, please describe:
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Your answer
Are you currently taking prescribed or over-the-counter medications, or herbal supplements or plant medicines? If yes, which ones?
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Your answer
Do you currently use alcohol or drugs? If yes, what kinds? How much daily or weekly?
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Your answer
Do you currently smoke cigarettes? If yes, since when? How many cigarettes daily?
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Your answer
Have you ever been hospitalized for a suicide attempt, drug or alcohol related issues, or mental illness? If yes, when? For how long? Where?
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Your answer
Have you received support for the issue you are seeking facilitation services in the past? If yes, when? With whom? For how long? What modalities?
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Your answer
Do you have a history of abuse or traumatic exposure? Please describe:
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Your answer
Please briefly describe why you are seeking services:
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Your answer
How did you learn about our services?
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Your answer
On a scale of 0 to 10, how distressed have you been during the last week?
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Not at All
0
1
2
3
4
5
6
7
8
9
10
Extremely
Are you experiencing thoughts of suicide either at present or within the past two weeks?
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Yes
No
As a result of services and/or courses, what do you most want to accomplish, i.e., resolve, change, discover?
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Your answer
Please type your name, including today's date, below, as a digital signature verifying that all of the above information is true and accurate.
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Your answer
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