Energy Healing with EFT, Kinesiology, Hypnosis, Aromatherapy, Reiki for Stress Management and Psychosomatic Issues in Brooklyn, NY and Asbury Park, NJ - HEIKE ZELNHEFER, LCSW

HEIKE ZELNHEFER, LCSW

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Adult Intake Form

As a new client, please complete the information below to the best of your ability.
The information you supply will enable me to provide a more effective service.

Basic Information About You

* Indicates required field

Name *

First

Last

Date of Birth *

Age *

For Transgender or Gender Fluid Individuals ONLY How would you like to be called? *

What Pronouns do you use? *

Address: Street *

Email *

Phone Number *

City, State, Zip Code *

May I send an email? *

May I leave a voice mail message? *

Who were you referred by? *

Emergency Contact: Name *

Emergency Contact: Relationship *

Emergency Contact: Phone Number *

Do you have any Legal History? *

Legal History explained *

Please list any past charges (alcohol / drug related - DUIs / DWIs, domestic violence, assaults, arrests, incarcerations etc) and list times...

Family Information

What is your Native Language? *

Relationship Status *

Do you have Children? *

Name and Gender of your Children *

Are your Parents alive / deceased? *

Do you have Siblings? *

How many siblings do you have? *

Education / Employment

Educational Level completed? *

Employment: Are you currently ... *

Have you served in the Military? *

Name of Employer / Length of Employment / Occupation *

Military Branch *

Do you have Combat Experience? *

How many times have you been deployed? If yes, how many Tours? *

Please fill this out if you have been deployed?

Discharge from the Military *

Medical History

Do you have any Medical Conditions? *

Medical Condition explained... *

Did you experience any trauma, accident, surgery etc... *

Trauma, Accident, Surgery explained *

Mental Health History

Family History of Mental Illness *

Family Mental Illness explained *

Family History of Suicide *

Family History of Suicide explained *

Have you ever been diagnosed with a Mental Illness *

Mental Illness Diagnosis explained *

If you ever have been diagnosed with any Mental Illness, please explain what your diagnosis was, who you were diagnosed by, and when you were diagnosed.

Have you ever received Mental Health Services *

Mental Health Services explained *

If you ever have received any Mental Health Services, please list the practitioners, year, and length of service.

Have you ever been a patient in a Psychiatric Hospital *

Psychiatric Hospital explained *

Please list the number of inpatient psychiatric hospitalizations you had in your life, when you were hospitalized and where.

Are you currently taking any Psychotropic Medication *

Psychotropic Medication explained *

If you are currently on or if you ever have taken any psychotropic medication, please list here.

Did you ever suffer any type of abuse *

Abuse explained *

Please explain what form of abuse you suffered (molestation, sexual abuse, emotional abuse, physical abuse etc) and how old you were

Within the past 3 months, did you have any suicidal thoughts *

Did you ever attempt suicide *

Do you have any thoughts of Self-Harm *

Suicidal ideation / Self Harm explained *

General Health Information

Do you exercise regularly *

Exercise explained *

Please list type and frequency (how often per day / week / month)

How many 8 oz glasses of water do you drink daily *

How many meals per day do you eat *

Meals explained *

Within the last 3 months, your appetite ... *

Within the last 3 months, your sleep ... *

Social Information

Alcohol Use *

Never Socially / Occasionally Once per month Once per week / Weekends Twice per week 3-5 times per week Daily Binge Drinking

Choose all that apply

Drug Use *

Never In the past / Not current Pain Medication / Opioids / Heroin Methadone Crack / Cocaine Marijuana Amphetamines / Ecstacy/ Molly Ayahuasca / Mescaline

Tobacco Use *

Never Cigarettes: less than a pack per day Cigarettes: 1 pack per day Cigarettes: more than a pack per day Cigars Vape

Alcohol / Drug / Tobacco Use explained *

Please list any past experiences, sobriety times, detox / rehab visits ...

Self Development

Do you meditate *

Meditation explained *

Please explain what form form of meditation you are practicing (guided v non-guided, silent, calming v insight oriented, focused, noting, body scan, visualization, loving kindness, awareness, skilled compassion, reflecting...)

Do you practice any religion / spiritual practice *

Religion / Spirituality explained *

If you practice any religion, please explain what faith you practice. If you are spiritual / believe in a higher power please explain

Please explain the reason you are seeking counseling at this time *

Thoughts & Feelings

Below is a list of different feelings and thoughts that affect Mind & Body. Please take a moment and check all that apply either currently or within the past 90 days (3 month).

Choose Any *

Afraid Angry Anxious Bullied Burdened Confused Defensive Depressed Desperate Disconnected Embarrassed Empty Frustrated Guilty Helpless Hopeless

Choose Any *

Homicidal Hurt Insecure Indifferent Impatient Irritated Lonely Lost Misunderstood Moody Numb Obsessive Paranoid Pessimistic Racing Thoughts Shameful

Choose Any *

Stressed Stuck Suicidal Tearful Unappreciated Unattractive Unfulfilled Unhappy Unlovable Unworthy Weary Worthless

Submit

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