From Anxiety to Inner Calm

Client Intake Form

Your information will remain confidential and will be used to personalize your wellness program. This program complements but does not replace medical or mental health care.

Personal Information

Full name

Date of birth

Phone

Occupation/profession

Emergency contact and phone

Your Current Concerns

How would you describe your anxiety and its symptoms in your own words?

How severe are your symptoms currently?

How often do you experience them?

Occasionally

A few times each week

Almost every day

Several times throughout the day

Triggers and Daily Life

How are these symptoms affecting your sleep, work, relationships, or daily life?

What usually helps you feel calmer?

Medical and Therapy History

Have you received a diagnosis related to anxiety or mental health?

Yes

Have you received therapy, counseling, or psychiatric care?

Currently receiving care

Previously received care

If applicable, please describe your therapy or counseling experience

Are you currently taking prescription medications, including medication for anxiety, mood, or sleep?

Yes

Physician or mental health provider's name

Do you have a family history of anxiety, depression, or another mental health condition?

Yes

Unsure

General Health and Lifestyle

Please list any important medical conditions, recent injuries, surgeries, allergies, or physical limitations

How would you describe your sleep?

Restful

Difficulty falling asleep

Frequently waking

Unrefreshing sleep

Do you regularly use caffeine, alcohol, tobacco, cannabis, or other substances?

Yes

Safety and Program Goals

Are you currently experiencing thoughts of harming yourself or someone else?

Yes

Prefer to discuss privately

What are your main goals for this eight-week program?

Is there anything else you would like me to know?

Acknowledgment

I understand that this is a complementary wellness program and does not replace medical care, psychotherapy, psychiatric care, or prescribed medication. I agree to inform the practitioner of any important change in my health, symptoms, or medications.

Client's name

Signature

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Date

Book your consultation: Complete Your Booking and Begin Your Personalized Journey

October 2026

Time zone: Coordinated Universal Time (UTC)Online meeting

Friday, Oct 23

Initial consultation fee

$200