Intake Self-Survey

Directions

For each item, state briefly how things are going and what you are concerned about. You can use words, a rating scale from 1-10, or emojis. You can write “no concerns” or “OK” for any area you don’t want to include in our work. Please include a bit of background information or history if that is important to you. Don’t worry about this…just the basics will be fine!

Please only fill this self-survey if this is your first time booking a consultation with me.

Thank you!