New Client Intake Form Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone * (###) ### #### Date of Birth * MM DD YYYY Gender * Female Male Other Prefer not to answer Emergency Contact * First Name Last Name Phone * (###) ### #### What is the relationship to you? * What kind of loss have you experienced? (please select all that apply) * Spouse Child Parent Sibling Friend Grandparent Pet Other When did you loss occur? * MM DD YYYY Are there any other losses you would like to disclose? (please select all that apply) * Divorce Miscarriage Stillbirth Identity Job Relationship Other How would you describe your current grief experience? (e.g: overwhelming, complicated, numb, fluctuating, etc.) * What are the most challenging aspects of your grief right now? (e.g: sadness, anxiety, isolation, difficulty functioning) * Do you experience any physical symptoms of grief? (e.g: fatigue, tension, headaches, changes in appetite or sleep) * Have you sought grief support or therapy before? * Yes No Do you have any existing mental health conditions or diagnoses? If yes, please explain. Are you currently taking any medications related to mental health? If yes, please explain. Do you have any coping mechanisms that help? (e.g: journaling, yoga, talking with family/friends) * Do you have any current thoughts of self-harm or suicide? * Yes No If yes, please elaborate so I can ensure you receive the right support. What would you like to gain from grief counseling? (e.g: coping strategies, emotional processing, self-care tools) * Are there specific types of support you are interested in? (e.g: talking therapy, mindfulness, yoga, nature, creative expression, movement, meditation). * Is there anything else you would like me to know? Thank you for completing the new client form!
