Session Intake & Release Form – All information shared herein is confidential
Please read through the following information fully. Please return at least 48 hours prior to your scheduled session. If not, we can go through the intake together during your session time. All information shared herein is confidential. If there’s anything you’d rather not share in writing here for any reason, please make note and be sure to share with me during your session.
Contact Info
- Your Name:
- Today’s Date:
- Phone: Mobile: Home: Work: Best to use:
- Your Email:
- Your Address:
- Emergency Contact:
- Their Phone:
- Your Relationship to Them:
- Your Gender at Birth
- Current Gender Identity
- Preferred Pronoun
- Your Age:
Birth Info
- Birthdate: Time: City: State or Country:
- Birth Order:
- Number of Siblings:
(Specify: Full, Half, Step and the age difference between you and them.) - Was your birth a difficult?
- Was your mother medicated? Rapid birth? C-Section? Forceps? Induced Labor? Other?
- Your Astrological Sign: Chinese Astrology Sign: Vedic Astrology Sign:
Relationship Status (Check all that apply)
- Single ___
- Separated ___
- Divorced ___
- Widowed ___
- Partnered ___
- Committed Relationship ___
- Married ___
- How long in this status?
- How are you with your status?
- If Partnered: Name of Significant Other: Their age:
Children (if any)
- Names and ages of children: (Specify if adopted, birth, or step-children)
- Names of other co-parents:
- In a few words, describe your relationship / current involvement with co-parents:
Mental & Emotional Health
- What is the current state of your mental health?
- Are you currently or have you ever been in psychotherapy?
- How would you describe your childhood?
- What is the current state of your emotional health?
- Have you experienced any significant traumas of any kind? Details:
- Do you take or have you ever taken anti-depressants, anti-anxiety or anti-psychotic medications? Details:
- What is your greatest mental / emotional concern at this time?
Physical Health
- What is the current state of your physical health?
- Do you have regular physical activity? If so, what is it?
- Do you have allergies? If so, please List:
- Women: Are you pregnant? How many pregnancies have you had? Births?
- Have you been diagnosed with any major disease/s?
- Have you ever been diagnosed with a neurological condition? Details:
If so, what treatment did you receive? - List your current medications (Please indicate what each item is for):
- Any significant accidents or physical traumas? Details:
- Any hospitalizations? Details:
- Describe your diet? (Check all that apply) Vegan __ / Vegetarian __ / Paleo __ / Fruits, veggies, some meat and few to no grains __/ Organic Foods __ / Mainstream Diet __ / Other __ / Please describe:
- Please indicate which of the following you are taking:
Vitamins / minerals / herbs / antioxidants / digestive enzymes, other…
Homeopathics? Yes / No __ Are you on a constitutional remedy? Yes / No __ - Substances:
- Do you use sugar? What form? How often?
- Do you use caffeine? What form? How often?
- Do you drink alcohol? What? How much? How often?
- Tobacco: Do you smoke, chew or vape? How much? How often?
- Do use marijuana? How often? If so, in what form?
- Have you ever used plant spirit medicine or psychedelic drugs?
- Are you currently using them? Details:
- Other?
Spirituality
- What was your religious upbringing?
- Your current religious or spiritual orientation:
- Do you have a daily spiritual practice?
• If so, what is it?
• Do you meditate? If so, how often?
Vocation
- What is your vocation?
- Is there a particular challenge or stress you experience with your work? Describe:
- Are you satisfied or fulfilled in your chosen work at this time?
Current Issues
- List your current physical, emotional, psychological and spiritual issues.
- Specify their duration.
- What is your understanding as to why these issues are present in your life?
- What, if anything, have you tried to address these?
- What’s helped and what has not?
- What are you most concerned about right now?
- What is your intention for creating this session at this time?
What are your longer-term goals for yourself?
Type of Session Desired
- A Distance Session via Phone (Zoom for International Clients) _____,
- An In-Person Session____ (You are fine with pets and incense.) (ONLY DISTANCE SESSIONS AT THIS TIME)
- Either is OK____.
How did you hear about me and my work?
Release
I _____________ (your full name) state that the information I have entered in the Intake above is true and correct, and that I have fully disclosed all conditions, diseases and issues. I have read the Session Information Form provided in full and agree to the terms and conditions contained therein.
I understand that Quiana Grace Frost does not diagnose or treat medical or psychological conditions as would a physician, psychotherapist or other licensed medical professional and as such, I do not expect any prescribed treatment or result. Any choices I make are my own and mine alone.
I hold Quiana Grace Frost, her landlord, spouse and heirs harmless.
I take full responsibility for my experience, releasing all others of responsibility for my well-being.
______________________________ ______________________________ ____________
Signature (or type if submitting electronically) Today’s Date
Emailing this completed form is the equivalent of a signature of acceptance.
Please email this completed document to me at least 24 hours prior to your session to the email below.