Client Intake Form

This will take about 20 minutes. You probably noticed that our homepage had an FAQ to answer your questions, so that we've answered all of them before your discovery call. This allows you to just focus on logistics. Likewise, this form answers our questions, so that we can focus efficiently during your discovery call and program. Please be in a place where you can finish in one sitting.

Full Name *

Phone *

Email *

Organization

Website

FACETIME number/name for sessions: (If applicable) *

ZOOM number/name for sessions: (If applicable) *

Do you authorize Stokes Mayfield, Jr. (or the assigned facilitator) to record (video) your sessions for training purposes? *

Yes

No

Do you authorize Stokes Mayfield, Jr. (or the assigned facilitator) to record (audio) your sessions for training purposes? (yes/no)

Yes

No

How did you get referred to or find out about us? *

PERSONAL INFORMATION

Date of birth

Address *

Street Address

City

State

Country

Postal code

Please indicate if mailing address is different than above address: *

Church you go to:

Your job, what do you do? *

Your age *

EMERGENCY CONTACTS

Name and phone number of two people to contact in case of emergency:

PAST HISTORY

id your birth mother or father have a similar issue as you are having? If so explain. *

What medications are you taking and what is each medication for? *

What mental disorders do you have? *

What emotional disorders do you have? *

What physical problems do you have? *

MOTHER

(Later questions will be for adopted, foster, step parents). If don't know, say N/A or Don't Know

Tell me about your childhood with your birth mother. Ages 5-10: *

What was the most hurtful thing your birth mother ever did to you? *

What was the most embarrassing thing your birth mother did to you? *

How did your birth mother treat your father? *

FATHER

(Later questions will be for adopted, foster, step parents). If don't know, say N/A or Don't Know

Tell me about your childhood with your birth father: Ages 5-10 *

What was the most hurtful thing your birth father ever did to you? *

What was the most embarrassing thing your birth father did to you? *

Other than your mother or father who hurt you the most in your childhood? What did he or she do? *

Other than your mother or father who hurt you most in your adolescence? What did he or she do? *

How did your birth father treat your mother? *

STEP-PARENTS, FOSTER, AND ADOPTED

If you had step-parents, foster parents or adopted parents and he or she hurt you tell me what happened: *

OTHERS THAT HURT YOU

Other than your mother or father who hurt you the most as a teenager? *

Other than your mother or father who hurt you the most as an adult? *

What did he or she do? *

RELATIONSHIP WITH GOD

Define in your words your relationship with God: *

THOUGHTS YOU HAVE ABOUT YOURSELF

Generally how do you feel about yourself?

Do you hate yourself? If so, why?

Do you not like yourself, if so, why?

Do you feel guilty, if so, why? *

When you do not live up to your own expectations or make a mistake what words do you speak to yourself? *

MARRIAGE

How many times have you been married? *

List the top three things that your spouse/partner does that cause you to be angry the most often, or triggers you. *

As a child do you remember your mother and father having a similar problem or issue as you now have with your spouse? *

List 3 things you would like to see your spouse do more often that would cause you to feel more loved. *

If you could change 3 things in your spouse/partner, they would be: *

If my spouse/partner could change 3 things in me, they would be: *

List 3 things you & your spouse/partner argue about the most. *

When your spouse/partner becomes angry with you, what do you do? *

When you are angry with your spouse/partner what does he or she do? *

SEXUAL ISSUES

Have you ever been molested or sexually abused? *

If so, by who *

What age were you *

What happened (details) *

How do you feel about yourself as a result of what happened *

Did you tell anyone, if so what was the reaction? *

If you did not tell, why not? *

How many sexual partners have you had? *

Have you been sexual with the same sex? *

Are you attracted sexually to the same sex? *

Yes

No

Have you been sexual attracted to animals? *

Yes

No

If female, can you have an orgasm? *

Yes

No

If female, can you only have an orgasm if you are in a certain position? *

Yes

No

If male, do you have erectile problems? *

Yes

No

Do you try to avoid sex? If so, explain *

Do you have a problem with sex? If so, explain. *

Do you now have or ever had an eating disorder? *

Yes

No

Have you ever been suicidal, if so, when and what was going on in your life? *

VOWS

When we are children sometimes our parents do things either to each other or to us that we vow when we become adults we will never do. Vows usually result in you doing the opposite extreme of your mother or father. Vows usually sound like:…. When I grow up I will never/ I will always

What vows did you make as a child? *

Why did you make this vow? *

Did you become like this person or the opposite of this person? *

OTHER DETAILS

Do you hear voices in your head? *

Is your mind extremely busy? If so, in your opinion why? *

Who else in your family line has had similar issues you are having such as your mother/father/grandmother/grandfather/great grandparents, etc.? How far back does this issue go in your family line? *