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Awaken Therapeutic Practice
Intake Form

Please fill out the following form to help us understand your physical condition.

First Name

Phone

Date of Birth

Last Name

Email Address

Emergency Contact (Please Add Name and Phone Number)

What is your intention doing therapy?

What is your experience with therapy?

Do you have any past history with trauma?

Is their anything that would assist in creating a safe and supportive space for our sessions?

Anything else you would like to share?

Are you currently suffering from a medical condition, illness, or injury? *

No

Yes

If you answered yes to any question, please elaborate

Initials

Today's Date

I declare that the info I’ve provided is accurate & complete

Looking forward to working with you.

© 2020 Kristin Luna Ray LLC

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