Application

Confidential

Holistic Intake

This is a confidential document. It includes several questions per category to get us started. We will discuss all of it. It’s intended to help me get a fairly good idea of who you are, and what categories of your life could be woven together to help us proceed. Please be as thorough as you can as I require screening for all individuals and couples.

Name

First Name

Last Name

Birth Date

Exact Time of Birth and Place

Emergency Person and Phone Number

How did you hear about One Journey?

1 ~ Mind

What is your overall feeling about life?

2 ~ Mind

Are you easily triggered?

3 ~ Mind

Do you have any psychological troubles: anxiety, depression, ADHD or PTSD?

4 ~ Mind

Are you quick to anger?

5 ~ Mind

Do your thoughts get the better of you?

6 ~ Mind

What traumas are you aware of? (big and little T)

7 ~ Mind

What kind of support system do you have?

8 ~ Body

Do you have persistent aches and pains?

9 ~ Body

Do you currently have health concerns?

10 ~ Body

Please share any surgeries or procedures which you've had.

11 ~ Body

Do you sleep well?

12 ~ Body

Do you take any medicines regularly?

13 ~ Body

Do you exercise regularly?

14 ~ Body

How do you feel about your body?

15 ~ Spirit

Do you have a mindfulness, breathing or meditation practice?

16 ~ Spirit

Are you a member of a faith based or religious organization?

17 ~ Spirit

Do you follow any recovery programs (12 step or otherwise)?

18 ~ Spirit

Do you appreciate alternative methods of spirituality?

19 ~ Sexual Wellness

Are you having the amount of sex that you would like to have?

20 ~ Sexual Wellness

When was the last time you had an amazing sexual encounter?

21 ~ Sexual Wellness

Do you feel safe asking for what you want?

22 ~ Sexual Wellness

Are there dysfunctions: painful intercourse, erectile issues, lack of interest, post-pardum issues, mismatched libido with your partner, incontinence or difficult periods?

23 ~ Sexual Wellness

Would you like changes in your sex life but don't know how to have that conversation?

24 ~ Sexual Wellness

Would you like to have better sex?

25 ~ Sexual Wellness

Is sex a barrier or does it cause problems in your relationship?

26 ~ Gut Health

Do you experience discomfort in your gut? Or have you been diagnosed with gut issues? (IBS, Crohn's, Leaky Gut, etc.)

27 ~ Gut Health

Do you experience regular bowl movements? Is there painful elimination? Infrequency? Too often? Banana-like consistency? Too loose? It all matters ;-)

28 ~ Gut Health

Do certain food have an impact on you?

29 ~ Gut Health

Please describe your relationship with food?