Mindful InnerChange Intake Form - Mindful InnerChange

CONTACT INFORMATION

First Name: *

Last Name: *

Date of Birth: *

Phone: *

Email Address: *

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code

Country

MEDICAL HISTORY

Injuries or physical conditions I should be aware of:

Primary Doctor Name:

List Medications Prescribed, if any:

Psychiatrist Name, if seeing one:

List Psychiatric Medications Prescribed, if any:

Psychologist, Counselor, Therapist Name, if seeing one:

CONCERNS AND INTERESTS

Check what you feel applies to you:Stress / TensionMemoryConcentrationAddictionsCompulsive BehaviorsAnxietyPanic AttacksDepressionLow Self-EsteemSleep IssuesFeelings of Guilt/Shame/RegretWeight ChallengesDishonestyRelationshipsSexualityShynessHeadachesIdentityWork/Career ChallengesPhysical PainCommunicationHealthUnhealthy PatternsMotivation Challenges

Describe Fears and/or Phobias, if any:

Describe any other concerns or interests:

LIFE EVENTS

Check what you experienced in the last 12 months:Death of a Partner, Child, or Someone close to youPregnancy Loss / TerminationDeath of a PetMarriageDivorce / SeparationMarital ReconciliationLoss of a JobRetirementChange in Health of a Family MemberPregnancyNew ChildSexual DifficultiesChange in Financial StateChange to a Different Line of WorkChange in Responsibilities at WorkSpouse Begins or Stops WorkChange in Living ConditionsChange in Recreation/Social ActivitiesChange in Eating Habits / DietChange in Spiritual Beliefs / PracticesAccidents / Surgeries

Describe any other life events you have experienced:

AGREEMENT AND DISCLAIMER

PARTICIPATION AGREEMENT *

I agree to participate in the healing process, and I realize it is not psychotherapy or a replacement of psychotherapy. I take full responsibility for consulting with a medical doctor or therapist regarding any concerns about my participation. I agree to hold Mecca Wagner-Brown and Shana Boyer harmless for any complications resulting from this work.

CANCELLATION / RESCHEDULE POLICY *

I understand Cancellations / Reschedules made 48 hours or less before an appointment will be subject to a $50 fee. No Shows will also be subject to this fee. Cancellations/Reschedule requests made via email to mindfulinnerchange@gmail.com or text Mecca at 480-482-8925 / Shayna at 480-818-3707 sooner than 48 hours before an appointment will be processed without penalty.

** This may change in the future but you will be notified prior to changes becoming effective

DISCLAIMER *

Mecca Wagner-Brown dba Mindful InnerChange and Shana Boyer dba Energetic Awakening does not provide medical diagnosis, or consultations related to health, medical or psychiatric issues; nor does it serve as substitute for medical or psychological diagnosis and treatment. It is recommended you see a licensed physician or licensed healthcare professional for any physical or psychological ailments you may have.

By utilizing the services and information provided by Mecca Wagner-Brown and/or Shana Boyer, you acknowledge and agree to fully release, indemnify, and hold harmless, Mecca Wagner-Brown and Shana Boyer, and others associated with Mindful InnerChange and Energetic Awakening, from any claim or liability whatsoever, including without limitation, direct or indirect, special, incidental, compensatory, exemplary or consequential damages, losses or expenses.

Any information, stories, examples, or testimonials presented on the Mindful InnerChange website do not constitute a warranty, guarantee, or prediction regarding the outcome of a treatment with Mecca Wagner-Brown and Shana Boyer. You may not disseminate, modify, copy, in whole or in part, such copyrighted material unless specifically permitted to do so by Mecca Wagner-Brown (dba Mindful InnerChange) and Shana Boyer (dba Energetic Awakening). By continuing to explore this website, or choosing to respond with and receive any services from Mindful InnerChange and/or Energetic Awakening, you agree to all of the above.

Client Signature *

Date: *

Please do not fill in this field.