Date Of Birth (Month, Day, and Year):

Email

Address:

Subject

Fitness/ Exercise Goal for Treatment Episode:

Please write your goal for physical fitness activity/ practice that you'd like to improve while attending Holistic Mental Health therapy? Ex. to go walking daily, to exercise at least 3x per week etc.

Nutrition Goal For Treatment Episode:

Please write your goal for nutrition practice that you'd like to work to improve while attending Holistic Mental Health therapy? Ex. To drink more water daily or To only eat takeout 1x per week etc.

Wellness/ Mental Health Goal For Treatment Episode:

Please write your gaol for wellness/ mental health practice that you would like to work to improve while attending Holistic Mental Health Therapy? Ex. to practice self care daily or to create a daily boundary practice at work etc.

What are your strengths?

Please list any character or personality strengths that you have identified about yourself.

What are your current growth opportunities?

Please list any character or personality growth opportunities or areas where you believe improvements can be helpful for your lifestyle.

Who are your supports?

Please list any family, friends, medical providers, or groups that help you feel supported.

What types of encounters cause you to feel triggered or agitated?

Please share interactions that you have with other people, places, and things that cause moderate to severe agitation, frustration, or stress.

What are your current coping strategies?

Please list ways that you manage your mood, stress, and self care needs.

Past or Current Mental Health Diagnosis:

Please list if you have been formally diagnosed with a mental health diagnosis by a doctor, counselor, or therapist. If not please write N/A

Ice Breaker: name your favorite role model:

Please list one of your favorite role models and what you like about the person you've listed.

New Client Intake Assessment Form