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Client Intake Form

Please take a few minutes to answer the questions below. All information will be kept confidential.

I look forward to meeting you!

First name*

Last name*

Date of Birth*

Email*

Phone

Ok to leave voicemail?*

Yes

No

Address*

Preferred Pronouns

Employment Status*

Full time

Part time

Self employed

Unemployed

Caregiver

Student

How did you hear about DYT?*

Structural Conditions

Please indicate which conditions you have experienced or diagnosed with in the past 5 years or more.

Multi choice

Back pain

Neck pain

Osteoarthritis

Repetitive strain injury

Degenerative disc disease

Chronic tendonitis

TMJ

Herniated/ruptured discs

Ankylosing Spondylitis

Sciatica

Scoliosis

Spinal stenosis

Spondylolisthesis

Osteoporosis

Other diagnosed structural condition

Please elaborate on anything you checked above, or add your own specific diagnosis below.

Mental / Emotional Conditions

Please indicate which conditions you have experienced or diagnosed with in the past 5 years or more.

Multi choice

Anxiety

Depression

Chronic stress

ADD

ADHD

Grief

Anger issues

Autism spectrum

Panic Disorder

PMDD

Acute trauma (as an adult)

Complex trauma (as an adult)

Sensitivity to sound, texture, atmosphere, etc

Eating disorder

Obsessive compulsive disorder (OCD)

Bipolar disorder

Borderline personality disorder

Post traumatic stress disorder

Substance use disorder

Other diagnosed mental/emotional condition

Please elaborate on anything you checked above, or add your own specific diagnosis below.

Physiological Conditions

Please indicate which conditions you have experienced or diagnosed with in the past 5 years or more.

Multi choice

IBS/IBD

Heartburn/GERD/Acid Reflux

Fibromyalgia

Interstitial cystitis / spastic bladder

Chronic tendonitis

Postural orthostatic tachycardia syndrome (POTS)

Circulatory conditions

Heart conditions

Fatigue / Chronic fatigue syndrome

Pulmonary conditions

Complex regional pain syndrome (CRPS)

Unexplained rashes

Multiple chemical sensitivities

Insomnia / Sleep issues

Cancer diagnosis

Allergies

Rheumatoid arthritis

POC

MS

Ehlers Danlos syndrome

Asthma

Diabetes

Epilepsy

High blood pressure

Glaucoma

COPD

Hypo/Hyperthyroidism

Graves disease

Cystic fibrosis

Non-alcoholic fatty liver disease

Hepatitis

Alcoholic fatty liver disease

Ulcerative colitis (UC)

Crohn's disease

Celiac disease

Chronic CBO

Hemmorhoids

Candida albicans overgrowth

Other

Please elaborate on anything you checked above, or add your own specific diagnosis below.

CNS Conditions

Please indicate which conditions you have experienced or diagnosed with in the past 5 years or more.

Multi choice

Tension headaches

Migraines headaches

ALS

Parkinson's

Essential Tremor

Balance

Alzheimers

Traumatic brain injury (TBI)

Peripheral neuropathy

Diagnosed Other CNS Condition

Please elaborate on anything you checked above, or add your own specific diagnosis below.

Other Symptoms

Please indicate which other symptoms you have experienced or diagnosed with in the past 5 years or more.

Multi choice

Muscle tenderness

Chronic tendonitis

Facial pain

Dizziness

Tinnitus

Numbness / Tingling sensations

Unexplained rashes

Multiple chemical sensitivities

Nausea

Hanger (Hunger + Anger)

Dry mouth / throat

Shakiness

Other symptoms

Please elaborate on anything you checked above, or add your own specific diagnosis below.

Adverse Childhood Experiences

Answer the following questions "yes, no, not sure". Then elaborate in the space below on anything you feel is important for me to know.

Have you, or your ancestors experienced significant historical, racial, or cultural traumas, like displacement, war, or even experiences related to genocide? For instance, Holocaust survivors? *

Yes

No

Not sure

Does your family have a history of violence, neglect, domestic abuse, substance use disorder, poverty, mental illness, racial, or sexual trauma? *

Yes

No

Not sure

Did a parent or other adult in the household often or very often… Swear at you, insult you, put you down, humiliate you, or act in a way that made you afraid that you might be physically hurt?*

Yes

No

Not sure

Did a parent or other adult in the household often or very often… Push, grab, slap, or throw something at you or another family member, or ever hit you so hard that you had marks or were injured?*

Yes

No

Not sure

Did an adult or person at least 5 years older than you ever… Cross any boundaries in a sexual way? *

Yes

No

Not sure

Did you often or very often feel that … No one in your family loved you, thought you were important or special, or your family didn’t look out for each other, feel close to each other, or support each other?*

Yes

No

Not sure

Did you often or very often feel that … You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you, or your parents were too drunk, high, or absent to take care of you or take you to the doctor if you needed it? *

Yes

No

Not sure

Have you lost a parent or other primary caregiver through divorce, abandonment, death, or other reason?*

Yes

No

Not sure

Has any immediate member of your household ever gone to jail or prison?*

Yes

No

Not sure

Elaborate on any of the above.

Surgeries / Other Medical Interventions

List any surgeries or other injuries that might be pertinent to your case, including approximate dates.

What Else Have You Tried?

Describe other treatments you have sought out for these issues.

Social Characteristics

Would your close friends/family describe you as a perfectionist?

Yes

No

Not sure

Would your close friends/family describe you as a problem solver?

Yes

No

Not sure

Would your close friends/family describe you as being rigid?

Yes

No

Not sure

What is your support system like?

Preferences and beliefs

What activities do you really enjoy?

What are your spiritual/religious leanings?

Do you suspect a connection between the boxes you checked in the different sections above? Elaborate if you can.

Indicate which therapeutic options appeal to you.*

Talk therapy (general)

Jungian analysis (exploring archetypes in life and in dreams)

Internal Family Systems

Movement therapy (issues in the tissues)

RX breath coaching

Incorporating faith/prayer

Meditation guidance

Lifestyle analysis and coaching / goal setting

Ayurvedic counseling (herbs, practices, lifestyle/dietary suggestions)

"White glove" referrals to other outstanding providers

Group classes / therapy

Monthly Jungian dream interpretation club

SUD recovery community

Polyvagal techniques

Monthly book club

Is there anything else you'd like me to know before submitting this form?

Thank you! On your first appointment, we will review this information and discuss any other pertinent information.

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