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WellBody Psychotherapy: Initial Intake Form

This survey will help us understand your needs and treatment goals so that we can match you with the best provider. Please answer the following questions to the best of your ability. We will then contact you via email to discuss your next steps in working with a WellBody provider. Thank you!
1.Full Name:(Required.)
2.Email Address:(Required.)
3.Phone:(Required.)
4.OK to leave voicemails?(Required.)
5.Date of Birth:(Required.)
6.Address:(Required.)
7.What chronic symptoms are you experiencing?(Required.)
8.When did your symptoms begin?(Required.)
9.Did you suffer from an injury? If so, when? Please describe.(Required.)
10.Do you have any test results/MRI findings? If yes, please describe.(Required.)
11.What is your current functionality?(Required.)
12.What do physicians say is the cause of your symptom(s)?(Required.)
13.What do you think is the cause of your symptom(s)?(Required.)
14.Did your symptoms begin during a time of stress, or do you notice your symptoms increase/get worse during stressful times?(Required.)
15.Are there any variations in the consistency of your symptoms (intensity, location, triggers, time of day, etc.)?(Required.)
16.Do you currently or have you previously suffered from:
Current
Previous
Anxiety
Depression
Eating Disorder
Trauma
Suicidal Ideation
17.Are you able to invest $165 - $250 per 50-minute session? WellBody does not directly accept any insurance, but can provide clients with a superbill or receipt for coaching services.(Required.)
18.Are you currently working with any other mental health providers?(Required.)
19.To help us filter out spam, please type the word “therapy” below.
(It helps us know you're a real person — and we really appreciate it!)(Required.)