Client Intake Form

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Client Intake Form

Blessings, Resilient One~

This client intake form is designed to help me identify the patterns in your life that have kept you stuck. It is my intention to help you reclaim your power so that you can create a thriving future self that supports your vision for health, happiness, and success.

As with any program, the key to success starts with YOU! My hope is that you are authentically and fully dedicated to your healing process as I am to you and your new journey ahead. 🙏

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Last Name, First Name *

Telephone *

Email Address *

Birthdate *

MM

/

DD

/

YYYY

Address, City, State, Zip *

How did you find me? *

Referral

Facebook

Instagram

LinkedIn

Google

Self-Confidence/Esteem *

Least satisfied or lowest rating

1

2

3

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5

Most satisfied or highest rating

Overall Stress level *

Least satisfied or lowest rating

1

2

3

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5

Most satisfied or highest rating

Energy Level *

Least satisfied or lowest rating

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2

3

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5

Most satisfied or highest rating

Rest/Sleeping Habits *

Least satisfied or lowest rating

1

2

3

4

5

Most satisfied or highest rating

Exercise Habits *

Least satisfied or lowest rating

1

2

3

4

5

Most satisfied or highest rating

Eating Habits *

Least satisfied or lowest rating

1

2

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5

Most satisfied or highest rating

Overall satisfaction of health *

Least satisfied or lowest rating

1

2

3

4

5

Most satisfied or highest rating

Quality of family relationship *

Least satisfied or lowest rating

1

2

3

4

5

Most satisfied or highest rating

Quality of friendships *

Least satisfied or lowest rating

1

2

3

4

5

Most satisfied or highest rating

Quality of business relationship *

Least satisfied or lowest rating

1

2

3

4

5

Most satisfied or highest rating

Ability to communicate effectively *

Least satisfied or lowest rating

1

2

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4

5

Most satisfied or highest rating

Ability to have fun - laughter/humor *

Least satisfied or lowest rating

1

2

3

4

5

Most satisfied or highest rating

Hobbies/Recreational activities *

Least satisfied or lowest rating

1

2

3

4

5

Most satisfied or highest rating

Consistent self-care routine *

Least satisfied or lowest rating

1

2

3

4

5

Most satisfied or highest rating

Overall balance/harmony in life *

Least satisfied or lowest rating

1

2

3

4

5

Most satisfied or highest rating

Describe any current addictions, including food, alcohol and cigarettes *

Describe your parents' relationship (past & present) and any other significant caregivers. *

Describe your infancy and childhood *

List age and details of childhood injuries, surgeries, illness, accidents and/or emotionally traumatic events *

List any recent injuries, surgeries, illnesses, accidents and/or emotionally traumatic events *

Describe current/most primary relationship. Married or have you been married? Children (ages, gender of each)? *

Describe any current/recent emotional challenges *

List any forms of past/present therapy. Describe any prior emotional process work.

What is your most negative thought about yourself, life, and your relationships? *

What is the emotion that is easiest for you to express? *

Anger

Sadness

Fear

Joy

What is the emotion that is the most difficult for you to express? *

Anger

Sadness

Fear

Joy

What are your major fears? How do you deal with fear? *

What are the things/person/situation that angers you the most? How do you deal with anger? *

Briefly describe any spiritual or religious beliefs. *

What would you like to accomplish with this work? *

Do you have any of the following conditions? If checked, please explain below as clearly as possible *

Stress

Allergies

Contagious disease

Diabetes

Back pain

Wear contact lenses

Pregnant

Cancer

Arthritis

Frequent headaches

Insomnia

Osteoporosis

Epilepsy/seizures

Bruise easily

Varicose veins

Cardiac/Circulatory problems

Very sensitive to touch or pressure

Anxiety, Depression, Bipolar Disorder

Accident or suffered any injuries in the past 2 years (broken bones, etc.)

Joint swelling, numbness or stabbing pains (specify below)

Tension or soreness in a specific area (specify below)

High Blood Pressure (if taking medication, please specify below)

Surgery in the past five years (specify below)

Other medical conditions (specify below)

Required

List any medications you are currently taking *

If you were hospitalized in the last 3 years, please explain the reason *

Are you under the care of a psychotherapist *

Yes

No

If yes, please provide their name and phone number

Emergency contact name & telephone number *

I understand the nature of the body-mind process and realize it is not psychotherapy or a substitute for psychotherapy. I take full responsibility for consultation with a medical doctor or therapist regarding any concerns about my participation. I agree to hold Emperador Enterprises/Sol Discovery/Jennifer Emperador not liable for any complications resulting from this work. I agree to participate with Emperador Enterprises/Sol Discovery/Jennifer Emperador in the process of my healing journey with the acknowledgement of my NAME & TODAY'S DATE below. *

LATE/NO SHOW/CANCELATION POLICY: Unless given prior notification, there is a 10 minute grace period in which a client can be considered tardy for their appointment. If more than 10 minutes late, she/he may be rescheduled based upon the practitioner’s availability or seen during their scheduled session time in which the session will end at the original allotted time. She/he will be charged full payment for their scheduled session even if tardy . No shows or cancellations that are not given at least 24 hour notice are also subject to full payment.Scheduled appointments: Full payment must be made at least 24 hours prior to scheduled appointment. Otherwise, they are subject to cancellation. Thank you! *

Yes

REFUND POLICY: To honor your needs, I put a lot of preparation into your session. There are no refunds available on sessions canceled within 24 hours. However, you may reschedule your session if canceled within 24 hours. Unused sessions may be gifted to a friend or family member. *

Yes

Disclaimer: Emperador Enterprises/Sol Discovery does not provide medical diagnosis or consultations related to health, medical or psychiatric issues; nor does it serve as substitute for medical or psychological diagnosis and treatment. It is recommended you see a licensed physician or licensed healthcare professional for any physical or psychological ailments you may have. By utilizing the services and information provided by Emperador Enterprises/Sol Discovery, you acknowledge and agree to fully release, indemnify, and hold harmless, Emperador Enterprises/Sol Discovery and others associated with Emperador Enterprises/Sol Discovery, from any claim or liability whatsoever, including without limitation, direct or indirect, special incidental, compensatory, exemplary or consequential damages, losses or expenses. Any information, stories, examples or testimonials presented on the Sol Discovery website does not constitute a warranty, guarantee, or predication regarding the outcome of a treatment with Emperador Enterprises/Sol Discovery. You may not disseminate, modify, copy, in whole or in part, such copyrighted material unless specifically or permitted to do so by Jennifer Emperador (Emperador Enterprises/Sol Discovery). By continuing to explore this website, or choosing to respond with and receive any coaching, breath work or energy sessions from Emperador Enterprises/Sol Discover, you agree to all of the above. *

Yes

602.502.0307 | Tempe, Arizona | www.soldiscovery.com

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