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Participant Intake Form -Form Fill

Q1

First Name

Name*
Q2

Last Name

Name*
Q3

Month

Birth Date*
Q4

Day

Birth Date*
Q5

Year

Birth Date*
Q6

Street Address

Address
Q7

Street Address Line 2

Address
Q8

City

Address
Q9

State / Province

Address
Q10

Postal / Zip Code

Address
Q11

Phone Number

Phone Number*
Q12

Email*
Q13

First Name

Emergency Contact Name
Q14

Last Name

Emergency Contact Name
Q15

Phone Number

Emergency Contact Phone Number
Q16

Do you have previous experience of journey work? Please share the broad details without using any identifying terms or names:
Q17

Describe any particular life circumstances that brought you to this work:
Q18

Do you have someone who can pick you up and be available to help you after your session?
Q19

Do you have someone who can you reach out to for help in integrating what you’ve experienced during your session?
Q20

Please list any current significant physical health issues:
Q21

Are you taking any prescription medication for physical conditions? If yes, what kind and reason?
Q22

Please list supplements that are part of an ongoing regimen:
Q23

Please list any allergies that require regular treatment and medication:
Q24

Which of these physical symptoms do you experience?
Q25

Have you ever been diagnosed by a psychologist or psychiatrist with a ‘mental illness’ or DSM disorder (such as major depression, borderline personality disorder etc)? If so, what was the diagnosis and when did it occur?
Q26

Please list any current significant mental health issues:
Q27

Are you taking any prescription medication for psychological conditions? If yes, what kind and reason?
Q28

Please list any stimulant or recreational drug use. Type and frequency:
Q29

Have you ever considered suicide? If yes, please briefly describe:
Q30

Are you currently followed by a mental health professional or counsellor? If yes, what kind and reason?
Q31

I would rate my current stress/anxiety on a scale of 0-10 (10 being high)
Q32

I have experienced the following:
Q33

Please comment on the most current significant source(s) of Stress and Anxiety
Q34

Which of these cognitive symptoms do you experience?
Q35

When you are stressed do you choose:
Q36

Do you take the edge off by:
Q37

Please provide any further details about your stress/anxiety and trauma history that you feel may be relevant.
Q38

How do you take care of yourself?
Q39

Who do you turn to for support?
Q40

Tell us about your strengths, hobbies, interests. What do you like to do for fun and relaxation?
Q41

Please describe your goals for this work:
Q42

Anything else you think we should know about you so we can provide you with the best support possible.
Q44

Signature (hold/click and sign with cursor)*