Schedule A Sessionoz@orbeenterprise.com2022-11-07T19:32:11+00:00 Liberate the Mind, Free the Soul. Schedule A Session 1 Session $150 2 Sessions $250 3 Sessions $350 Client Intake Questionnaire The information provided on this form is protected as confidential information. Personal InformationName Home/Cell PhoneEmail May we leave a message? Yes No Date MM slash DD slash YYYY Age Gender Marital Status: Never Married Separated Domestic Partnership Married Divorced Widowed Which of the following applies to you? Business Owner Employed Unemployed HistoryHave you previously received any type of: Mental Health, Psychotherapy, Psychiatric services? Yes No General and Mental Health InformationHow would you rate your current physical health? Poor Satisfactory Good Very good Please list any specific health problems you are currently experiencing:How would you rate your current sleeping habits? Poor Satisfactory Good Very good Please list any specific sleep problems you are currently experiencing:How many times per week do you generally exercise? What types of exercise do you participate in? If yes, for approximately how long?Are you currently experiencing overwhelming sadness, grief or depression? Yes No Please list any difficulties you experience with your appetite or eating problems:Are you currently experiencing anxiety, panics attacks or have any phobias? Yes No If yes, when did you begin experiencing this?Are you currently experiencing any chronic pain? Yes No If yes, please describe:Do you drink alcohol more than once a week? Yes No How often do you engage in recreational drug use? Daily Weekly Socially Never Are you currently in a romantic relationship? Yes No If yes, for how long?On a scale of 1-10 (with 1 being poor and 10 being exceptional), how would you rate your relationship?What significant life changes or stressful events have you experienced recently?
