NEW CLIENT INTAKE FORMFill out information to your best ability Please Select New Client Existing Client Name * First Name Last Name Email * Phone # * (###) ### #### Date of Birth / Age Occupation # Of Children Relationship Status Can you identify any emotions or feelings that are affecting your daily life? Check all that apply: Anger Irritability Depression Sadness Hopelessness Grief / Loss Doubt Anxiety Overwhelm Burn Out / Exhausted Feel numb / shutdown Unmotivated Low Self-Esteem Resentment Negative Thoughts Family Stress Relationship Stress Work Stress Experiences From Past Resurfacing Fear of Future Other - Use box below Provide any additional emotions or feelings you would like to share: Provide any health ailments or physical pain you are experiencing: This area can also be discussed in a Healing Session. We may briefly touch on this in our session. PLEASE NOTE: In our session we will address 1 concern to begin. A follow-up session may be needed to continue addressing the concern and/or any additional concerns you have listed. We will address your next concern if time allows. What concern would you like to address in our first session? Provide as much information as you would like. If there is time what is the second concern would you like to address in our session? Provide as much information as you would like. Prior to Session - Additional Information Once your intake form is received I may reach out prior to your session via email or phone/text for additional information/clarification to better maximize and prepare for our session together. Scheduling Your Session What times and days work best for you? Select ALL that apply I will be in contact via email or text within 24 hours to schedule your session. Monday - evening Tuesday - evening Wednesday - evening Thursday - evening Saturday - mid morning Sunday - mid morning Provide up to 3 dates that would work for you for a session Week nights beginning 5:30PM EST and after | Weekends 11:00am EST and after Session Length First Session is 1hr 30min. If you need other options please specify below: 1 hr 30 min Works For Me Need 1 hr Would like 2hrs Virtual Sessions What platform do you prefer: FaceTime video Zoom video By Phone (no video) Cost: $75 Sliding Fee Options (if in financial need) are available. Please select what payment amount works for you: $75 Sliding Fee $70 Sliding Fee $65 Sliding Fee $60 Sliding Fee $55 Payment Options Payment is due within 24 hrs after completing session. Please select what option works well for you. Venmo @ArtistNichole-Rae Apple Pay 949-294-8260 Paypal @Nicholerae1985 Check Mail to 108 Linden Road St Augustine FL 32086 Disclaimer * I am fully aware and agree that this session is not to diagnose any physical and/or mental health condition(s). It is not meant to replace professional medical advice. Any techniques used are not a sole form of treatment for mental, emotional and/or medical problems. The intent for this session is to provide information to help in the healing process for your emotional and spiritual wellbeing. Yes No Thank you for filling this intake form out. I look forward to our session together. Your intake form as been submitted. I look forward to our upcoming session together.
