INTAKE FORM

Ok to leave voicemail?

Yes

How did you hear about DYT?

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

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

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

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

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

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

Central Nervous System

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

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

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

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

Adverse Childhood Experiences

Childhood trauma causes extreme stress on your body. Over time this stress becomes toxic. Your ANS becomes chronically elevated (toxic stress) leading to changes in immunity, breathing, heart rate, blood sugar regulation, quality of sleep, emotional regulation, concentration, and pain processing.

Knowing your score underscores the critical need for daily nervous-system down-regulation.

Research suggests that a high ACE score is directly linked to negative health and wellness in adulthood. Adults with 4 or more ACEs were 12 times more likely to develop chronic conditions. (Cleveland Clinic)

For every "yes" you answer, add 1 to your score. A higher ACE score

Did you feel that you didn’t have enough to eat, had to wear dirty clothes, or had no one to protect or take care of you?

Yes

Not sure

Did you lose a parent through divorce, abandonment, death, or other reason?

Yes

Not sure

Did you live with anyone who was depressed, mentally ill, or attempted suicide?

Yes

Not sure

Did you live with anyone who had a problem with drinking or using drugs, including prescription drugs?

Yes

Not sure

Did your parents or adultsin your home ever hit, punch, beat, or threaten to harm each other?

Yes

Not sure

Did you live with anyone who went to jail or prison?

Yes

Not sure

Did a parent or adult in your home ever swear at you, insult you, or put you down?

Yes

Not sure

Did a parent or adult in your home ever hit, beat, kick, or physically hurt you in any way?

Yes

Not sure

Did you feel that no one in your family loved you or thought you were special?

Yes

Not sure

Did you experience unwanted sexual contact (such as fondling or oral/anal/vaginal intercourse/penetration)?

Yes

Not sure

To the best of your knowledge, did your parents, grandparents, great grandparents experience adverse conditions such as abuse, SUD, mental illness, poverty, racial or ethnic discrimination, displacement, or ethnic cleansing.

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.

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

Yes

Not sure

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

Yes

Not sure

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

Yes

Not sure

What is your support system like?

Preferences and beliefs

What activities do you enjoy? What subjects are you interested in?

What are your spiritual/religious leanings?

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.

Structural

Mental / Emotional

Physiological

Central Nervous System

Other

Adverse Childhood Experiences

Other

What Else Have You Tried?

Social

Preferences and beliefs