New Client Intake Form | Sonia Niebergall

First name

Last name

Email

Phone

In order to see if my level of training and competence is appropriate to support you & in case of an emergency, I will need you to fill in this form. Everything will be kept confidential.

By checking this box, I understand and agree to the CONFIDENTIALITY & LIABILITY, Financial Agreement, & Informed Consent Forms. You can view and download via this link if you choose.

https://www.sonianiebergall.com/terms-and-conditions

Who referred you?

Date of Birth

Emergency Contact Name

Emergency Contact Relationship to you

Emergency Contact Phone #

Reason for initial visit?

Are you under the care of a mental health professional presently or have you been in the past year? Answer Yes or No

Yes

No

If yes, please list the name and number of your mental health professional in case of an emergency? (I will not contact them unless there is an emergency or you give me written permission.)

Please describe any mental health conditions you have been diagnosed with?

Are you under the care of a physician presently or have you been in the past year? Answer Yes or No

Yes

No

If yes, please list the name and number of your medical health professional in case of an emergency. (I will not contact them unless there is an emergency or you give me written permission.)

Do you have any condition that would prevent you from tapping acupoints on your body?

Yes

No

If yes, please describe.

Do you have any breathing disorders like asthma or sleep apnea, or any disorder like epilepsy that may be triggered by relaxation or changes in breathing or intensity of emotion? Answer Yes or No

Yes

No

If yes, please describe

If you have a medical or psychiatric episode while we are working together, how would you like to be helped?

Are you on any psychotic drugs, or have you been in the past? Answer Yes or No

Yes

No

Are you taking any medications today that have a numbing effect, like Benzodiazepines/diazepam? Answer Yes or No

Yes

No

Do you drink alcohol or take any mind altering substances presently or have you in the past year? Answer Yes or No

Yes

No

What support do you have at home or elsewhere?

Your Signature: Type your full first and last name

Today's Date